THIS  BOOK  WAS  DONATED 


OPERATIVE    SURGERY 


OK    Till: 


NOSE,   THROAT,    AM)    EAR 


OPKKATIVK  SIKGI'IKY 


OF  THE 


NOSE.  THROAT.  AM)  KAK 


FOR   LAHVN(i()LO(iISTS.   RIIIXOLOCilSTS,  OTOLOGISTS. 
AM)  SUKCiKOXS. 


BY 


HANAU  W.  LOEB,  A.M..  M.I). 

PROFESSOR  OF  EAR.  NOSE  AND  THROAT  DISEASES  IN  ST.  LOl'IS  I'NIYERSITY 

IN  COLLABORATION  WITH 

Joseph  C.  Beck,  M.D.,  R.  Bishop  Canfield,    M.D.,    George  W.  Crile.   M.D..    Eugene  A.  Crockett,   M.D..   William 

H.  Haskin,  M.D.,   Robert  Levy,  M.D.,  Harris  P.  Mosher,  M.D.,  George  L.  Richards,  M.D.. 

George  E.  Shambaugh,  M.D.,  and  Georse  B.  Wood.  M.D. 


IX  TWO  VOLUMES 


VOL.  I 


FOUR  UUMHiKl)  AX  It  XL\K  ILL  r  STRAT 


ST.  LOUIS 

C.  V.  MOSBV   COMPANY 

1914 


COPYRIGHT,  191-4. 

(All  Kit/lit*  AVxr /TCI/.) 


PREFACE. 

This  work  was  undertaken  at  the  suggestion  of  many  colleagues, 
with  no  little  misgiving-  on  the  part  oi'  the  author.  To  lighten  the 
burden  and  to  make  the  publication  more  effective,  it  was  divided  among 
collaborators  who  were  specially  qualified  i'or  the  assignee  I  topic.-. 

The  endeavor  has  been  to  present  the  operative  surgery  of  the 
nose,  throat  and  ear,  unaccompanied  by  any  discussion  of  pathology, 
etiology  or  symptomatology.  The  method  of  operating,  the  indica- 
tions, the  contraindications,  after-treatment  and  results  have  been 
considered  paramount  for  the  purposes  of  this  work. 

The  illustrations  are  practically  all  original,  the  majority  of  them 
being1  drawn  expressly  for  this  work.  They  are  planned  to  make  the 
text  clear  without  too  great  a  sacrifice  of  detail. 

The  first  volume  deals  with  the  more  general  subjects,  such  as 
the  surgical  anatomy  of  the  nose,  throat  and  ear,  the  external  surgery 
of  the  throat,  the  direct  examination  of  the  larynx,  trachea,  bronchi, 
esophagus  and  stomach,  and  the  operations  made  possible  through 
its  agency,  and  the  plastic  surgery  of  the  nose  and  ear. 

Volume  IT  is  to  he  devoted  to  the  more  specialized  surgery  of 
the  nasal  cavities,  the  pharynx  and  larynx,  which  has  been  developed 
during  the  years  of  laryngologic  and  otologic  activity,  since  the  laryn- 
goscope was  devised. 

(irateful  acknowledgment  is  here  made  to  the  many  who  have 
by  their  efforts,  advice  and  encouragement  rendered  this  publication 
possible,  to  Mr.  A.  Schwitalla,  S.  ,1.,  who  was  of  great  assistance  in 
reviewing  the  text,  to  the  collaborators,  and  to  the  publishers,  whose 
patience  has  been  most  commendable. 

n.  w.  L. 


CONTRIBUTORS  TO  VOL.  1. 

JOSEPH  C.   IJKCK.  31.  1).,  CHICAGO. 
Professor  of  Otology,   Rhinology  and   Laryngology,   University  of   Illinois. 

GEORGE   \V.  CRILE.  M.  D.,  CLEVELAND. 

Professor  of  Surgery,  Western   Reserve   University. 

IIAXAT    \V.    LOEIi.   M.  1)..  ST.    Louis. 
Professor  of  Ear,   Nose  and  Throat  Diseases,   St.    Louis   University. 

HARRIS   P.   MOSIIER.   M.  I)..    UOSTOX. 
Assistant  Professor  of  Laryngology,  Harvard  Medical  School. 

GEORGE    E.    SIIAMP>AUGH.    M  I)..    CHICAGO. 
Associate   Professor   of  Laryngology   and   Otology,   Rush   Medical   College. 

GEORGH    I.J.    WOOD.    M.  I)..    PIIILAPKLIMIIA. 


(Vll, 


r  o  \  T  K  N  r  s. 

(MIA  I'T  E  K     I. 

TIIIO    Sl'KCJN'AL    AXATOMV    OK    Til  10    NOSIO. 

External  Xose   i 

Xasal   Cavities    •>, 

Floor  of  the  Nose — Septum  Nasi — Roof  of  the  Nose — External  Wall  of  the  Xosc 
—The  Choamr. 

Accessory  Sinuses  of  the  Xose 11 

Frontal   Sinus — Maxillary   Sinus — Ethmoid   Cells — Sphenoid   Sinus. 

Variations  of  the  Sinuses  in  Size  and  Shape :!n 

Frontal  Sinus — Maxillary  Sinus — Ethmoid  Cells— Ethmoid  Labyrinth— Ante- 
rior Ethmoid  Cells — Posterior  Ethmoid  Cells — Sphenoid  Sinus. 

Superficial  Area  and  Cubical  Capacity  of  the  Sinuses :\f, 

Optic  Chiasm  and   Nerve 4u 

Xasolacrimal   Duct    50 

I  lypophysis  (  Pituitary  Body  )    f,U 

Vascular  Supply   .'!' 

Arteries — Veins. 

ImnTvation    ~,'.\ 

Sympathetic  System. 

CHAPTER     II. 
SKKlilCAL    AXATOMV    OK    THE    PILVRVXX.    LARVXX.   AND    XIOCK. 

THE   PHARYXX. 

Xasopharynx   ."> 

Pharyngeal   Tonsil. 

Oropharynx fiH 

Palatal  or  Faucial  Tonsil — Pillars  and  Lateral  and  Posterior  Walls. 

Laryngopharynx  63 

Lymphatics  of  the  Pharynx   64 

Nerves  of  the  Pharynx   6~> 

Structures  of  the  Pharyngeal  Wall 66 

Superior  Constrictor  Muscle — Middle  Constrictor  Muscle — Inferior  Constrictor 
Muscle  —  Palatopharyngeal  Muscle  —  Stylopharyngeus  Muscle  —  Palatoglossus 
Muscle — Azygos  Uvula1  Muscle — Levator  Palati  Muscle — Tensor  Palati  Muscle. 

THE   LARYXX. 

Superior  Division    7n 

Ventricular  Bands. 

Middle  Division  

Inferior   Division    

Cartilages  of  the  Larynx   71 

Cricoid  Cartilage — Arytenoicl  Cartilages — Thyroid  Cartilage — Epiglottic  Car- 
tilage— Lesser  Cartilages. 

(ix) 


CO  NTH  NTS. 


Articulations  and   Ligaments  of  the  Larynx  .....................................          73 

Joints  —  C'ricothyroid  .Membrane  —  Thyrohyoid  Membrane  —  Inferior  Thyroary- 
tenoid  Ligament—  Superior  Thyroarytenoid  Ligament  —  Ligaments  of  the  Epi- 
glottis. 

Muscles  of  the  Larynx  .........................................................          75 

Cricothyroid  Muscle  —  Posterior  Cricoarytenoid  Muscle  —  Arytenoid  Muscle  — 
Lateral  Cricoarytenoid  Musclt  —  Thyroarytenoid  Muscle  —  External  Thyroary- 
tenoid Muscle  —  Thyroepiglottic  Muscle  —  Internal  Thyroarytenoid  Muscle  — 
Action  of  the  Muscles. 

Nerve  Supply  of  the  Larynx  ....................................................          79 

Superior  Laryngeal  Nerve  —  Internal  Laryngeal  Nerve  —  External  Laryngeal 
Nerve  —  Recurrent  or  Inferior  Laryngeal  Nerve. 

THE  LYMPHATIC  SYSTEM  OF  THE  NECK. 

Lymphatic  System  of  the  Neck  ..................................................          79 

Suboccipital  Group  of  Glands  —  Mastoid  Group  —  Parotid  Group  —  Subparotid 
Glands  —  Submaxillary  Group  —  Facial  Glands  —  Submental  Group  —  Retrophar- 
yngeal  Group  —  Descending  Cervical  Chain  of  Lymph  Nodes  —  Accessory  or  Su- 
perficial Descending  Cervical  Chain  —  Supraclavicular  Group  of  Lymph  Glands. 

TOPOGRAPHIC    ANATOMY    OF    THE    ANTERIOR    CERVICAL    TRIANGLE. 

Topographic1  Anatomy  of  the  Anterior  Cervical  Triangle  .........................          85 

Sternocleidomastoid  Muscle  —  Submaxillary  Salivary  Gland  —  Digastric  Muscle 
—  Stylohyoid  Muscle  —  Facial  Nerve  —  Internal  Jugular  Vein  —  Hypoglossal 
Nerve  —  Common  Carotid  Artery  —  Omohyoid  Muscle  —  External  Carotid  Artery 
-Superior  Thyroid  Artery  —  Ascending  Pharyngeal  Artery  —  Lingual  Artery  — 
Facial  Artery  —  Occipital  Artery  —  Posterior  Auricular  Artery  —  Internal  Max- 
illary Artery  —  Superficial  Temporal  Artery  —  Internal  Carotid  Artery  —  Pnen- 
mogastric  or  Vagus  Nerve  —  Superior  Laryngeal  Nerve  —  Recurrent  or  Inferior 
Laryngeal  Nerve  —  Spinal  Accessory  Nerve  —  Glossopharyngeal  Nerve  —  Pharyn- 
u»-al  Plexus. 

CHAPTER     III. 

TIIK    sriHJK'AL    ANATOMY    OK    TIIK    KAR. 

Introduction    .................................................................  (.i|t 

Development  of  the  Temporal   Hone  .............................................  '.Hi 

Meat  us  Auditonus   Externus   ...................................................  102 

I'roce.ssus    Mustoidcus    .........................................................  1<>S 

'  'a  v  ti  m  Tympani    ...............................................................  lit! 


C  II  A  PT  E  R     I  V. 

KNTKRNAL     OI'KKATIONS     OK     TIIK     LARYNX.     1'IIAUYNX.    KIM'Klf 
KSOI'HAU'S.    AND    TK'ACIIKA. 

Special   I  >i  flic  ult  jeS  and    Dangers   ................................................        ll.'5 

Pneiniinnia      Local    Infection      Mediastinal    Abscess—  Vagit  is      Reflex    Inhibition 
'i   'In-  Heart  ami   Respiration  Through  Mechanical  Stimulation  of  the  Superior 
Laryimcal    Nerves      Selection   and    Care   of  Trach"al    Cannula. 
Operations   on    the   Trachea    ..................................................        i:!n 

Kiner;v  ncv    Tracheotomy        Planned     Tracheotomy  -  -  Tracheal 
lei  care  dt   the  I'aii'iit      Closure  of  a  Tracheotomy     Cicatricial  Steno- 
Trachea 


c<>.  \TK\TS. 


Surgery  of  the  Larynx   ...................................................  ]  ;;x 

Laryngectomy  for  Intrinsic  Cancer  —  Anesthetic  in  Laryngectomy  -  Technic  of 
Laryngectomy  —  Extrinsic  Cancer  of  the  Larynx  —  Stenosis  of  the  Larynx. 

Surgery  of  the  Pharynx  and  Esophagus  .........................................        1  4S 

Cancer  of  the  Pharynx  and    Esophagus  —  Excision   of  the  Tonsil    for   Cancer 
Cancer  of  the  Pillars  —  Stenosis    of    the    Pharynx  —  Esophagostoiny-    Cancer  of 
the  Esophagus  —  Diverticula  of  the  Esophagus. 

C  II  A  PT  E  R     V. 

LARY\(JOSCOPY.     TKACI1KOSCOPY.     I5KONCIIOSCOPY.     KS(  >PII  A(  JO- 
SCOP  Y.    AX  I)    (JASTROSCOI'Y. 

THE    DIRECT    EXAMINATION    OF    THE    LARYNX. 

General  Considerations   ........................................................        \~\~, 

Historical  —  Contraindications  —  Choice  of  the  Anesthetic  —  Cocainization  —  Dif- 
ficulties of  the  Examination. 

Method  of  Making  the  Direct  Examination  ......................................       ir>8 

Passing  the  Speculum  from  the  Corner  of  the  Mouth  —  Direct  Examination  with 
Counter  Pressure  —  Direct  Examination  Under  Ether  —  Instruments  for  Direct 
Examination  —  Inhalation  of  Oxygen. 

Suspension  Laryngoscopy  ......................................................        167 

TRACHEOBRONCHOSCOPY. 

r,ower  Tracheobronchoscopy   ...................................................       17" 

Contraindications  to  Lower  Tracheobronchoscopy  —  Anesthesia  —  Position  of  the 
Patient  —  Method  of  the  Examination  —  The  Endoscopic  Picture  —  Interpretation 
of  the  Endoscopic  Picture  —  Choice  of  the  Upper  or  Lower  Route  —  Dangt  rs  of 
Bronchoscopy  —  Asepsis  —  Size  of  the  Tubes. 

BRONCHOSCOPY. 

Lower  Bronchoscopy   ...........................................................        IS'1 

Upper  Bronchoscopy  ...........................................................        1S7 

Anesthesia  —  Method  of  Performing  Upper  Bronchoscopy  —  Introduction  of  the 

Bronchoscope  with  the  Patient   Lying  on  His  Back  —  Upper  Bronchoscopy  with 

the  Jackson  Tubular  Speculum  and  the  Jackson  Bronchoscope  —  Introduction  of 

the  Bronchoscope  with  the  Open  Speculum. 
Examination  in  Children  ............................................  IS'.1 

Instruments  —  Direct  Laryngoscopy  —  Method  of  Examination  —  Lower   Broncho- 

scopy —  Upper  Bronchoscopy. 
Instruments   for    Bronchoscopy    ........................................... 

Jackson    Tubular    Speculum  —  Brunings'    Elongating    Bronchoscope  —  Briinings' 

Elongating   Forceps  —  Batteries  —  Aspirator    for    Removing    Secretions  —  Acquir- 

ing Skill. 
Direct  Laryngoscopy  for  Diseased  Conditions  ........ 

Malignant  Disease  —  Non-Malignant  Disease  of  the  Larynx  —  Tuberculosis  of  the 

Larynx  —  Inflammatory    Diseases  —  Malformations    of   the     Larynx,     Congenital 

and  Acquired. 
Retrograde  Laryngoscopy  ............. 

Tracheobronchoscopy  in  Diseases  of  Trachea  and  Bronchi.  . 

Stenosis  of  the  Trachea  —  Treatment. 


Xll  COXTKXTS. 

PAGE 

REMOVAL  OF  FOREIGN  BODIES  FROM  THK  LARYNX.  TRACHEA 
AND  THE  BRONCHI. 

Foreign   Bodies  in   tin-   Larynx -02 

Removal  df  Foreign  Bodies  from  Trachea  and  Bronchi 203 

Choice    of    the     Upper   or   Lower   Route — Indications — Dangers — Danger   from 
Leaving  Foreign  Body  Aloiu — Results — Symptoms — Diagnosis — Physical  Signs 
Location — Technic  of  Removing  Foreign  Bodies — After-effects  of  Removal  of 
Foreign   Bodies. 

ESOPHAGOSCOPY. 

Esophagoscopy   210 

History— Anatomy — Structure — Lymphatics — Position  —  Direction  • —  Diameter 
—  Length  of  Esophagus — Distensibility — Subphrenic  Portion  of  the  Esophagus 
— Movements  of  the  Esophagus — Measurements  of  the  Esophagus — Contraindi- 
cations to  Esophagoscopy — Anesthesia — Instruments — General  Examination  of 
the  Patient — Technic  of  Esophagoscopy  Under  Cocain  Anesthesia — Position  of 
the  Patient  —  Introduction  of  the  Esophagoscope  by  Sight — Introduction  of  the 
Esophagoscope  by  Means  of  a  Flexible  Mandarin  or  Bougie — Introduction  of 
the  Esophagoscope  1'nder  General  Anesthesia — Use  of  the  Adjustable  Speculum 
for  Introduction  of  Esophagoscopo — Passing  the  Jackson  Esophagoscope  by 
Sight  —  Passing  the  Oval  Tube  by  Sight — Passing  the  Esophagoscope  by  Aid 
of  a  Mandarin  or  Flexible  Bougie — Appearance  of  the  Normal  Esophagus. 

THE    DISEASES    OF   THE    ESOPHAGUS. 

Acute   Inflammation    232 

Stenosis  of  Esophagus   Due  to  Cicatrices 232 

Location  of  Strictures — Diagnosis  and  Treatment  of  Esophageal  Strictures — 
Cases  of  Stricture — Use  of  a  Thread  as  a  Guide  in  Esophageal  Strictures — 
After-care  of  Strictures  of  the  Esophagus. 

Spastic  Stenosis  of  the   Esophagus 24n 

Esopliagospasm-    Cardiospasm — Phrenospasm. 

R<-nign   New  Growths  of  the   Esophagus 247 

Treatment    of  Benign   New   Growths. 

Malignant   New  Growths  of  the  Esophagus   24S 

•\Mnptoms  of  Cancer  of  the  Esophagus — Diagnosis  of  Cancer  of  the  Esophagus 
DiaLMiosis  and  Treatment   of  Cancel-  of  the   Esophagus. 

i  'o m |>n  s.-ion   S teii ds is  of  the   Esophagus 2"> 4 

I  iif  lam  mat  ion  and    Clcerat  ion  of  the   Esophagus 2f>  1 

Chronic   Inflammation   of  the   Esophagus-     I'lceration   of  the   Esophagus. 

leurosis  of  i  he  EsophaLMis   LTitl 

Neurosis  of  the    Esophagus      Paralysis  ;md    Paresis  of  the    Esophagus. 

•  uital  Anomalii  s  of  the  Esophagus L'.'T 

Stricture  of  the   Esophagus      Divert  iculuni. 
K  ophagiiK 
in   ili"   E.--r  ipl  i  at;  us 

'      Fon-k'Ji     I'.odies     Lodue        Procedure    to    be     Followed     in     Cases 

'    «:   the  Anesthetic     Coins  and   Buttons  in  the  Esoph- 
Pins  in  the  Esopliagus     Safely  Pins  in  the  Esopha- 


CONTENTS. 


GASTROSCOPY. 

I'AfJK 

Gastroscopy  ........................................................  L>71 

History  —  Usefulness  —  Instruments  —  Technic  of  Gastroscopy  —  Position  of  tin- 
Patient  —  Passing  the  Gastroscope  —  Area  of  the  Stomach  Which  Can  be  Kx- 
plored  —  Contraindications  —  Dangers  —  Difficulties. 

The  Stomach  as  Seen  Through  the  Gastroscope  ..................................       276 

Normal  Stomach  —  Movements  of  the  Stomach  —  Gastritis  —  Peptic  Ulcer  —  Malig- 
nant Diseases  of  the  Stomach  —  Gastroptosis  and  Gastrectasia. 


CHAPTER     VI. 

PLASTIC    SURGERY    OF    TIIK    NOSE    AND    EAR. 

General  Considerations   ........................................................       279 

History  —  Important  Factors  —  Covering  Defects  —  Recording  Cases  Before,  Dur- 
ing and  After  Correction. 

RHINOPLASTY. 

Rhinoplasty   ..................................................................        288 

Classification  of  Nasal  Deformities  —  Method  of  Procedures  in  Nasal  Deformi- 
ties and  Malformations. 

Correction  of  Unilateral  and  Partial  Deficiencies  of  the  Nose  .....................       291 

Legg's  Operation  —  Koenig's  Operation  —  Von  Esmarch's  Operation  —  Von  Lan- 
genbeck's  Operation  —  Dieffenbach's  Operation  —  Von  Esmarch's  Operation  — 
Busch's  Operation  for  Partial  Loss  of  Tip  and  One  Side  of  Nose  —  Nelaton's 
Operation  —  Syme's  Operation. 

Correction  of  Total  Loss  .......................................................        295 

Helferich's  Operation   (French  Method). 
Correction  of  Sunken  Bridge,  Upturned  Lobule  or  Tip,  and  Saddle-back  ..........       298 

Roberts'  Operation  for  Sunken  Bridge  with  Upturned  Lobule  or  Tip  of  Nose  — 

Roberts'  Operation  for  Sunken  Saddle-back  Nose. 
Formation  of  a  New  Columella   ................................................       301 

Dieffenbach's  Operation  —  From  the  Dorsum  of  Nose  (Hindoo  Method)  —  Lexer's 

Operation  for  Formation  of  Columella   (from  Mucous  Membrane  of  the  Upper 

Lip). 
Italian  or  Tagliacozzi's  Method    ................................................        305 

Israel's  Operation  —  Dieffenbach's  Operation  —  Nelaton's  Operation. 
Hindoo  or  Indian  Method  ......................................................       310 

Thiersch's  Operation  for  Total  Loss  of  Nose  —  Nelaton's  Operation   for  Total 

Loss  —  Koenig's  Operation  for  Subtotal  Loss  —  Nelaton's  Operation  for  Subtotal 

Loss  —  Von  Langenbeck's  Operation  for  Collapsed  Nose  —  Schimmelbusch's  Op- 

eration  for  Total   Loss  —  Schimmelbusch's   Operation     for    Saddle-back   Nose  — 

Sir   Watson    Cheyne's    Operation  —  Von    Hacker's    Operation  —  Sedillot's    Opera- 

tion for  Total  Loss. 
Double  Transplantation  Method  ................................................ 

Steinthal's  Operation  for  Total  Loss  —  Kausch's  Operation  for  Collapsed  Nose. 
Finger  Method  ................................................................ 

Watt's  Operation  for  Subtotal  Loss  —  Wolkowitsch's  Operation  for  Total  Loss  — 

Von  Esmarch's  Operation  for  Collapsed  Nose,  Etc. 
Clavicle  Method   .  335 


XIV  CONTEXTS. 

PAGE 

Implantation  Method    337 

Israel's  Operation  for  Saddle-back  Nose — Goodale's  Operation  for  Depressed 
Nose — Ouston's  Operation  for  Depressed  Nose  Below  the  Bridge — Carter's  Op- 
eration for  Saddle-back  Nose — Beck's  Operation  for  Saddle-back  Nose — Wal- 
sliau's  Operation  for  Collapsed  Ala? — Lambert's  Operation  for  Collapsed  Alse. 

Paraffin  Injections  in  Nose  and  Ear  Deformities 344 

History — Indication — Results — Technic  of  Injections — Injections  in  Nasal  De- 
ficiencies— Injections  in  Kar  Deficiencies — Injections  in  Collapsed  Ala\ 

Reduction  Method   354 

Joseph's  Operation  for  Reducing  Hump,  Length,  Width  of  Nose,  and  Large 
Nostrils — Kolle's  Operation  for  Hump  Nose — Beck's  Operation  for  Hump  Nose 
— Ballenger's  Operation  for  Hump  Nose — Ballenger's  Operation  for  Long  Nose 
—  Roe's  Operation  for  Hump  Nose,  Twist  and  Broad  Ala  or  Large  Nostrils — 
Roe's  Operation  for  Broad  Ala?  or  Large  Nostrils — Beck's  Operation  for  Hump 
Nose — Kolle's  Operation  for  Long  Tip  Nose. 

Prothetic  or  Artificial  Noses   36l' 

Artificial  Supports. 

Orthopedic  Method    362 

Operations  for  Closing  Perforating  Septum   364 

Goldstein's  Operation — Hazeltine's  Operation  for  Perforation  of  Septum — Gold- 
smith's Operation  for  Closure  of  Septal  Perforations. 

OTOPLASTV. 

Classifications  According  to  Kolle   366 

General-  Consideration     367 

General  Classification   367 

I'sual  Operation  for  Macrotia — Parkhill's  Operation  for  Macrotia — Cheyne  and 
Burghard's  Operation  for  Macrotia — Goldstein's  Operation  for  Macrotia — 
Goldstein's  Operation  for  Projecting  Kar — Beck's  Operation  for  Roll  Ear  or  So- 
called  Dog  Kar — S/ymanowski's  Operation  for  Reconstructing  an  Auricle — 
Beck's  Operation  for  Synechia  or  Auricle  to  the  Mastoid  Squama — Roberts' 
Operation  for  Absence  of  Kar — Simple  Operation  for  Colobomata — Green's  Op- 
eration for  Colobomata— Monk's  Operation  for  Prominent  Kar — Kolle's  Opera- 
tion for  Projecting  Kar. 

Posiaurirular   Deficiencies  or  Retroaiiricular  Fistula1 :!78 

Trautnianifs  Operation  for  Closure  of  Posterior  Deficiencies- --Von  Mosetig- 
Moorliol!  Operation  Goldstein's  Operation—  Kar  Prothesis. 

NKFROPLASTV     FOR     FACIAL     PARALYSIS. 

.\>-uro|>la.-t>    for   Facial    Paralysis    

Spin" -Fa< -ial   and    Periphero-Spinal   to    Descendens   llypoglossi   Anastomosis.. 


Facial-Spinal     Anastomosis      Facial-1  lypoglossal     Knd     to    Side    Anastomosis 
l-'acjal  I  lyjioulossal   Knd  to  Knd  Anastomosis     Myeloplasty  for  Facial   Paralysis. 


ILLl'STKATIONS. 

I'll;.  PACK 

1.  The  cartilages  of  the  nose;    lateral  view 

1'.  The  cartilages  of  the  nose;  anterior  view 

:!.  The  orifices  of  the  nose  showing  a  dissection   of  the  crnra   medialia  of  the 

cartilagines  alares  niajores    ;; 

4.  Floor  of  the  nose   4 

5.  The  sept  inn    nasi    5 

ii.  The  right   outer  wall  of  the  nose c, 

7.  The  left  outer  wall  of  the  nose  with  the  concha  media  removed 

S.  The  choame  and  anterior  wall  of  the  sphenoid  sinus  viewed  from  behind.  ...  1» 

!».  The  left  orbit :   bone  relations 11 

1(1.  Left  orbit  with  bone  removed  exposing  the  mucosa  of  the  accessory  sinuses..  lii 

11.  Hones  of  the  nose  and  orbits;   external  plate  over  frontal  sinuses  removed...  i:', 

12.  Floor  of  the  anterior  cranial  fossa;   bony  roof  of  accessory  sinus  removed   in 

part 14 

Coronal  section  through  the  nose  and  orbit l.~> 

Right  lateral  view  of  bones  of  the  face  with  maxillary  sinus  and  roots  of  the 

teeth   exposed    17 

1").      Sagittal  section  through  the  right  side  of  nose  and  maxillary  sinus.    External 

portion 

It).      Sagittal  section  through  the  right  side  of  the  nose.     Internal  portion 

17.     Sagittal  section  through  the  left  side  of  the  nose  internal  to  that  of  Figs.  15 

and  ItJ.     Inner  portion   L'n 

IS.      Sagittal  section  through  the  left  side  of  the  nose  internal  to  that   of  Figs.  15 

and  It).     External  portion   _1 

l!i.     Coronal   section   through   nose  and   orbit   three  mm.   anterior  to  the  anterior 

wall  of  the  sphenoid  sinuses 

20-34.     Lateral  and  superior  reconstruction  of  the  accessory  sinuses  of  the  nose..     25-i'Ji 

:'.5-40.     Plaster  casts  of  sphenoid  sinuses,  placed  in  situ :',4-l!'.' 

41-55.     Preparation  showing  relation  of  optic  nerve  to  accessory  sinuses  of  the  nose.    4<i-4'j 

56.  Right  lateral  wall  of  the  nose  with  exposure  of  ihe  saccus  nasolacrimalis  and 

ductus  nasolacrimalis    5i> 

57.  Coronal   section   through  the  sphenoid   sinuses,   removal    of    septum    sinuum 

sphenoidalium  and  exposure  of  the  hypophysis fil 

58.  Median  section  through   face  of  an  adult  man.  showing  the  normal   relations 

of  the  structures  during  quiet  nasal  respiration 56 

5!i.     Median  section  through  the  face  of  an  infant  one  month  old.  showing  the  rela- 
tions of  the  structures  during  quiet  nasal  respiration   57 

HO.     Transverse  section  through  the  head  of  a  child  one  month  old  just   in   front 

of  the  posterior  pharyngeal  wall    

The  region  of  the  palatal  tonsil , 

Dissection  of  the  region  of  the  palatal  tonsil  from  the  outside 

Dissection  showing  the  relation  of  the  tensor  palati   and   the   levator   palati 

muscles  .  6S 


xvi  ILLUSTRATIONS. 

KK, 

H4.  Tlii-  lateral  external  surface  of  the  larynx  ..................................  <o 

65.  The  muscles  of  the  laryngeal  wall  on  the  posterior  aspect  ..................          76 

»;•;.  Diagrams  illustrating  closed  and  open  glottis  ..............................          78 

67.  Dissection  showing  the  upper  deep  cervical  lymph  nodes  ................... 

6v  Superficial  dissection  of  the  carotid  triangle   ...............................          S6 

6'.<.  Dissection  of  the  pes  anserinus  of  the  facial  nerve  .......................... 

7".  Deep  dissection  of  the  carotid  triangle   .................................... 

71.  The  relation  of  the  palatal  tonsil   to  the  vessels  and  nerves    of    the    carotid 

triangle  ..............................................................          -'6 

7l'.  Temporal  hone  from   new-born  ...........................................        101 

7:',.  Temporal  hone  from  child  one  year  old    ..................................        1"! 

74.  Temporal  bone   from  child  three  years  old   ................................        103 

75.  Temporal  bone  from  child  ten  years  old   ..................................        103 

76.  Frontal  section   through  the  adult   temporal   bone:    the  anterior  part  viewed 

from  behind  ..........................................................        !"•* 

77.  Adult   temporal   bone  showing  the   position   of  the  antrum   tympanicum   and 

mastoid  cells  along  the  upper  posterior  wall  of  the  external  canal  .........        104 

7s.     Horizontal  section  through  the  temporal  bone  viewed  from  above  ............        105 

7'.'.     Section   through  mastoid  process  and  external  canal   .......................        105 

ML  Section  through  temporal  bone,  showing  the  relation  of  the  facial  canal  to 

the  fenestra  vestibuli  and  of  the  horizontal  canal  to  the  antrum  ..........        106 

Section  through  temporal  bone,  exposing  the  facial  canal  ...................        107 

Adult  temporal  bone,  showing  anatomic  relations  after  a  complete  tympano- 

mastoid  exenteration    ..................................................        107 

Adult  temporal  bone,  showing  the  typical  relation  of  the  linea  temporalis 

extending  in  a  horizontal  direction  back  from  the  external  canal  .........        1(|S 

Adult  temporal  bone,  showing  the  linea  temporalis  making  a  marked  curve 

down   along  the  posterior  border  of  the  external    meatus    before    turning 

backward   .   .    ..........................................................        10T» 

Adult  temporal  bone  showing  the  linea  temporalis  making  a  curve  upward 

at  the  posterior  margin  of  the  external  meatus   .........................        110 

Section  through  mastoid  process,  antrum  tympanicum,  and  external  canal...        Ill 
Pneumatic  type  of  mastoid.     Larger  cells  arranged  along  the  periphery  ......        Ill' 

I.  Section  through  temporal  bone.  Section  passes  through  antrum,  vestibule 

and   internal  meatus   ...................................................        11:: 

Section  through  temporal  bone,  showing  relation  of  the  horizontal  canal  and 

facial  canal   to  the  middle  ear  chambers;    also  relation   of  the  carotid  and 

ami  Iml  bar  jugular  is  to  the  cavum  tympani    .............................         111'. 

Section  through  the  mastoid  process,  showing  but  partial  pneiimat  ization  .  .  .  114 
Dipld-tic  type  of  mastoid.  Complete  absence  of  pneumatic  spaces.  Antrum 

tympanicum  contracted    ................................................        11  ; 

Section  through  adult  temporal  bone,  showing  persistence  of  infantile  type 

v.  it  h  absence  ot   pneumal  jc  spaces  in   the  mastoid  ........................         115 

Section  through  adult  temporal  bone,  showing  the  relations  of  the  carotid  to 

'I'1'  cavum  t  \inpani  and  the  structures  in  the  floor  of  the  recessus  opitym- 

paniciis  .......................................................         1  ],; 

S'-'-tjon    through    mastoid,    cavum    tympani.    tuba    auditiva,    showing    a    large 

'  ubal  ce||  .  -  - 


1  IS 
ll!» 


ILLrSTKATloNS.  XVI! 

Kid.  r\i, I 

US.     Section  through  temporal  bone,  showing  relation   of  the  bulbus  jngularis  to 

cavuin  tynipani  and  relations  of  the  cochlea  and  facial  canal  to  the  cavuin 

tympani   l^u 

W.      Horizontal  section  through  the  temporal  bone  seen  from  above li'j 

UMi.     View  of  the  posterior  aspect   of  the  temporal   bone,  showing  bulbus  jngularis 

extending  to  the  upper  margin  of  the  petrous  bone   

101.     Tracheotomy  under  local  anesthesia;    novocaini/ing  the  skin    

In:.'.     Tracheotomy.      Incision  through  thyroid  gland  and  trachea ]:>,;; 

lo;:.     Tracheotomy.      Xovocainizing  the   trachea   from    within l:;4 

104.     Tracheotomy.     After  the  operation  \-.\~, 

10f>.     Laryngectomy.     Preliminary  tracheotomy  with   iodoform  gauze  packing 141 

lot!.     Laryngectomy.     Five  days  after  preliminary   tracheotomy.     Arrangement    of 

tube  for  anesthesia   14l' 

107.  Laryngectomy.     Separation  of  the  larynx  from  the  esophagus 14:; 

108.  Laryngectomy.     Closure  of  pharyngeal  opening 144 

10!i.      Laryngectomy.     Closure  of  wound  with  iodoform  gauze  packing 14f, 

110      Ksophagostomy.     Ample  incision  of  skin  along  the  anterior  border  of  sterno- 

mastoid   muscle    i  r>2 

111.      Ksophagostomy.     Exposure  of  esophagus   \~>?, 

IIH.     Ksophagostomy.     Esophagus  stitched   to  skin    ir>4 

11:1.     Jackson's  tubular  speculum    Ififi 

114      Diagrammatic  representation  of  direct   laryngoscopy 16o 

llf>.     Position  of  second  assistant  and  patient  for  endoscopy  per  os 161 

lit!.     Bronchoscopy  room  at  Massachusetts  General   Hospital 162 

117.  Mosher's  adjustable  speculum    16:! 

118.  Mosher's  adjustable  speculum   164 

li;i.     Forceps  for  direct  work  upon  the  larynx   166 

ll'u.     Killian's  suspension   apparatus    168 

121.  Mosher's  folding  frame  for  suspension  apparatus,  closed 16(» 

122.  Mosher's  folding  frame  for  suspension  apparatus,  open 16H 

123.  I'rethrascope  used  as  a  tracheoscope 170 

llM.  Trethrascope  used  as  a  tracheoscope,   showing   individual   parts 171 

12").  Jackson's  bronchoscope    173 

126.  Jackson's  bronchoscope,   with   beveled   end    173 

127.  Cast  of  the  interior  of  the  trachea  and  bronchi,  with  their  chief  ramifications 

within  the  lung   174 

128.  Cast  of  the  interior  of  the  trachea  and  bronchi,  with  their  chief  ramifications 

within  the  lung 1" 

1211.     The  arch  of  the  aorta,  with  the  pulmonary  artery  and  chief  branch    of    the 

aorta   l~t> 

130.  Showing  the  relation  of  the  trachea  to  the  great  vessels  of  the  neck.  .  177 

131.  Showing  the  divisions  of  the  trachea,  and  bronchi 

132.  Showing  the  relation  of  the  main  bronchi  to  the  ribs  and  the  chest  wall   (An- 

terior view )    1 ' !l 

133.  Showing  the  relation  of  the  trachea  and  main  bronchi  to  the  chest  wall  and 

ribs   ( Posterior  view )    

134.  Diagram  to  show  the  bronchoscopic  picture.. 

135.  Diagrammatic  drawing  to  show  the  bronchoscopic  picture  at  various  levels.  . 

136.  Horizontal  section  of  thorax  of  man.  aged  f>7.  at  the  level  of  the  upper  part  of 

-i  c   1 

the  superior  mediastinum    


\Y111  ILLUSTRATIONS. 

KIi..  I'ACK 

i:'-7.  Horizontal  section  of  thorax  of  man.  aged  57,  immediately  above  the  bifurca- 
tion of  the  trachea  18.") 

l:',S  Horizontal  section  of  the  thorax  of  a  man.  aged  57.  at  the  level  of  the  roots 

of  the  limits  186 

l:!9.     Horizontal  section  of  the  thorax  of  a  man,  aged  57,  at  the  level  of  the  nipples.  187 

140.  Briinings'   electroscope    191 

141.  Rheostat    and   battery    19:! 

142.  Coolidge's  cotton  carrier 194 

14::.      Angular  forceps  for  use  with  the  adjustable  speculum 104 

144.  Mosher's  alligator  forceps   194 

145.  Jackson's  tube   forceps    195 

146.  Coolidge's   forceps    195 

147.  Killian's  manikin  for  practicing  bronchoscopy  and  esophagoscopy 196 

148.  Hriin ings'  elongation    forceps    197 

149.  Tips   for  Bninings'   forceps    197 

150.  Kxpanding  tip  for  I'.riinings'  forceps   197 

151.  Mosln  r's  spiral  wire  forceps  for  removing  papilloma  of  the  larynx 198 

152.  Mosher's  triangular  fenestrated  tube   198 

15:1.      Small  bronchoscope  for  emergency  intubation 199 

154.  Pin  with  glass  head  in  left  main  bronchus 208 

155.  f'assolberry's  pin  cutter    2"9 

156.  Section  of  the  human  esophagus    (Moderately  magnified  ) 211 

157       Showing  the  relations  of  the  esophagus  from  behind 212 

15s.      View  of  the  stomach  in  situ  after  removal  of  the  liver  and  the  intestine 213 

159.      ("nd'T  surface  of  the  diaphragm    214 

I*'.'  .      Schema  showing  the  range  of  motion  of  the  gastroscope 215 

161       Jackson's  esophagoscope 21S 

16u.      Mosher's  short  length  oval  osophagoscope 219 

16:i.      Mosher's  <  sophagoscope    (short    length) 22" 

164.  Hood  or  cap  which  protects  the  lamp 22o 

165.  Lonu  conical  plunger  for  Mosher's  oval  esophagoscope 22" 

166.  Window   plug   for   making   the  osophagoscopo    air    tight     and     ballooning     the 

esophagus 22" 

K7.      hifferent  six.es  of  Mosher's  oval  esophagoscopes   22" 

The  normal  <  sophagus  above  the  hiatus  of  the  diaphragm,  and   with   the  dia- 

phraiMii    cont  racted    I'L'!* 

Ksopha::oscope  puslnd  through  the  hiatus  of  the  diaphragm  and  entering  the 

subphronic  portion  of  the  esophagus   l'l".i 

IT1*       K-<,phai:oscopc  carried  tlirough  the  cardiac  opening  of  the  esophagus  into  the 

stomach    ;j;_>'.i 

171       The  ,  sophagus  just    above  t  lie  hiatus  of  t  lie  diaphragm 229 

Norn. a  I  <  sophauus  (luring  quiet    breathiim    

Normal  esophagus  during  deep  respiration    

•' '  '   ci  in    oi  esophagus  \\  it  h  scars  rad iat  ing  from   its  lumen 

1  7.".  1  7"'>      '  'a  re  in  (i  ma   of  the  esophagus    

1  7  i        K         done  in   iliciso|ihauus   

li'  i       ':.'  '  : .;:  i:  i'-a !   (1  i  hit  or-   with   t  u  o  i  i  ps 

I'.uni       olive-l  ipp(  d    in.  tal    hoimie 

Strict  .    ophaiiiis    

"i    I'lummer's  esophagcal    whalebone   bougies.  . 


ILLCSTHATIONS.  XIX 


182.      Whalebone  stalT  of  Plummer's  esophageal   bougie  ..................  239 

IS',',.     Metal  stalT  carrying  olive  at  tip;  special  wire  carrier  ..............  L':',!i 

184.  Mosher's  two-bladed  dilator  with  sliding-  knife  .............................        LMu 

185.  Cardiospasm.     Retouched  tracing  from  an  X-ray  plate  ............  I'll 

186      Apparatus  for  dilating  the  cardia  .........................................        243 

187.  Cardiospasm.     Print  of  an  X-ray  plate  showing  a  dilated  esophagus  .....  210 

188.  Section   of  normal   esophagus    (  Low   power)  ................................        24X 

189.  Carcinoma  of  the  esophagus   ..............................................        nr,n 

190.  Section  of  careinomatous  area   (Low  power)  ..............................          251 

191.  Section  of  careinomatous  area   (High  power)    ..............................        252 

192.  Careinomatous  stricture  of  the  esophagus  .................................        252 

193.  Cancer  of  the  esophagus.     Retouched  tracing  from  X-ray  plate  ..............        253 

194.  Forceps  with  punch  tip   ..................................................        255 

195.  Mosher's  curette   ......................................................... 

196.  Jackson's  foreign  body  forceps    ........................................  ... 

197.  Penny  lodged  in  the  upper  part  of  the  esophagus  of  a  child  ................. 

198.  Penny  whistle  in  the  upper  part  of  the  esophagus  of  a  seven  year  old  child.  . 

199.  Safety  pin   in   the  esophagus  .............................................. 

200.  Jackson's  forceps  for  grasping  and  pushing  open  safety  pins  into  the  stomach 

for  turning    ........................................................... 

201.  Schema  showing  Jackson's  method  of  removing  an  open  safety  pin   from  the 

esophagus  by  passing  it  into  the  stomach  ................................ 

202.  Mosher's  safety  pin  removing  tube   ....................................... 

20?).     Mosher's  safety  pin   forceps    .............................................        2~n 

204.  Tooth  plate  in  the  esophagus   .............................................        27" 

205.  Mosher's  instrument  for  cutting  a  tooth  plate  or  large  pieces  of  bone  ........        271 

206.  Jackson's   bronchoscope,   esophagoscope   and   gastroscope  ....................        272 

207.  Position  of  the  right  hand  during  the  introduction  of  the  gastroscope  .......        274 

208-210.      Historical  illustrations  of  Tagliacozzi's  work    ..........................        280 

217-222.     Appliances  and  instruments  employed  by  Tagliacozzi  ....................        281 

22:!,      Incisions  and  flaps  for  closing  defects   (Celsus  )    ............................        284 

Making  Reverdin   graft    .................................................. 

Reverdin  graft  applied   ................................................... 

Making  and  applying  Thiersch  graft   ......................................        2SO 

Stereoscopic  photograph  of  plaster  cast   ...................................        2S7 

228-229.      Legg's  operation    for  correction   of  unilateral   and   partial   deficiencies   of 

the  nose   ..............................................................        291 

Kocnig's   operation    ................................................... 

Von  Esmarch's  operation    ............................................          292 

Von   Langenbcck's  operation    .............................. 

Dieffenbach's    operation     .............................................. 

238.  Von   Esmarch's   operation    ................................................ 

239.  Busch's  operation  for  partial  loss  of  tip  and  one  side  of  nose  .......  294 

240.  Xelaton's  operation    ........................... 

241-242.     Syme's    operation    ............................................... 

243-244.     Helferich's  operation  for  total  loss  of  nose  ..... 

245-247.     Roberts'  operation  for  sunken  bridge1  with  upturned  lobule  or  tip  of  nose. 
248-251.      Roberts'  operation  for  sunkt  n  saddle-back  nose   .... 

252-25:].      nieftVnl;ach's  operation  for  formation  of  new  columella  from  the  upper  lip. 


XX  1 1. LUSTRATIONS. 

IK, 

2.">4-2.">.     Operation   for  formation  of  now  columolla  from  the  dorsum  of  the  nose. 

I  Hindoo  method  )    

2~>6-260.     Lexer's  operation  for  the  formation  of  columella  from  the  mucous  mem- 
brane of  the  upper  lip 

2H1-2G2.     Italian  or  Tagliacoz/.i's  method 

2t'.3.     Italian  or  Tagliacozzi's  method   

2»;4-2tir>.      Israel's   operation    

2i;»;-2tiS.     Dieffenbach's  operation   

20!»      Xelaton's  operation    

27^-271.     Xelaton's  operation    

•21-      Hindoo  or  Indian  method  of  flap  formation   

273.     Thiersch's  operation  for  total  loss  of  nose 

274-27'i.     Xelaton's  operation  for  total  loss  of  nose 

277-27!*.     Koenig's  operation   

I'M i -L'Sl.     Ke<  Bail's  operation  for  subtotal  loss  of  nose,  in  cases  of  hacked  noses.  ... 

2S2-2Sr,.     Xelaton's  operation  for  subtotal  loss  of  nose 

2SO-2S7.     Von    Langenbeck's  operation   for  collapsed   nose;    making  supports,   espe- 
cially when  soft  parts  are  wanting 

288-2!*d.     Sehimmolbusch's  operation   for  total  loss  of  nose   

2K1-2H3.     Sehimmelbusch's  operation   for  saddle-back  nose   

i".' l-L'!t7.     Sir  Watson  Cheyne's  oi>eration.      (Indian  method.)    

2!*8-3dd.      Von   Hacker's  operation.      (Indian   method.)    

3dl-:{d2.     Sedillot's  operation  for  total  loss  of  nose.     (Indian  method.) 

3n:,-3d4.     Steinthal's    operation    for    total   loss    of    nose.      (Double    transplantation 

method.  )   328 

3"."i-3ntj.     Kausch's  operation  for  collapsed  nose.     (Double  transplantation  method.)        329 

3o7.      \\'att's  operation  for  subtotal  loss  of  nose    331 

3HX-311.     Wolkowitsch's  operation   for  total  loss  of  nose.      (Finger  method.) 332 

312.      Von   Ksmarch's  operation   for  collapsed  nose  or  absence1  of  the  promaxilla  or 

an  anterior  perforation  of  hard  palate   334 

3i:;-314.     Clavicle  method.      ( Gustav  Mandry. )    334 

31.">.      Israel's  operation   for  saddle-back  nose   338 

.",  Ki-31  !i      (loodalf's  o])eration   for  depressed  nose   33!) 

32o-:;L'l.     Oust on's  oiteration   for  depressed  nose  below  the  bridge    34(1 

".I'l'M'  1       Carter's  ope  rat  ion   for  saddle-back  nose   M41 

:;^.V:;LM;      Carter's  openition   for  saddle-back  nose   342 

Walshou's  ojierat  ion   for  collapsed  ahe M44 

!2!"       I'arafliiioina    with   attempted    removal.      Facing   l>age 3yd 

'•'.'•',»       Heck's  paraffin  syringe    ;{f>l 

.losepii's   operation    for    reducing   hump,    length,    width    of   nose   and    large 

nost  rils :!f)4 

!.">.      Kol  le's  ope  rat  ion    for  hump   nose    3r>r» 

17.      Heck's  op(  rat  ion   lor  hump  nose   I'lfiTi 

I'.a  I !'  HL'i-r's  o])i  ra!  inn    for  hump  nose    3f> 7 

I'.alleuui  r's  operai  ion  for  long  nose   3.r>7 

II       Ko"'s  operation    for  hump,   tuist    and   broad   ala   or  large  nostrils.      (Illus 

t  rat  id    by    Heck.)     :',f»8 

17.      Hoe's  operation   for  broad  ala-  or  large  nostrils.      (Illustrated  by   Heck.)..        .'{(id 

H"<-k's  op"  rai  ion  for  hump  nose   :{(io 

1        Koll'-V   operation    tor    lonu   tip    3(!1 


ILLUSTRATIONS. 


3f>2-3r>f>.     Prothetic  or  artificial  noses   

356-358.     Goldstein's  operation  for  perforation  of  septum   

359-361.     Hazeltine's  operation   for  perforation  of  septum   

362-364.      Usual  operation   for  maerotia   

365-366.     Parkhill's  operation  for  maerotia   

367-368.     Cheyne  and   Hurghard's  operation   for  maerotia    

369-371'.     Goldstein's  operation   for  niacrot  ia    

373-376.     Goldstein's  operation   for  projecting    far    

377-379.     Heck's  operation   for  roll  ear  or  so-called   dot;  ear   

380-381.     Szymano\vski's  operation  for  reconstructing  auricle   

382.     Heck's  operation  for  synechia  of  auricle  to  mastoid   

383-386.     Roberts'  operation  for  absence1  of  ear  

387-388.     Simple  operation  for  colobomata   

389-390.     Green's  operation   for  colobomata    

391.     Monk's  operation   for  prominent  oar   

392-393.     Koile's  operation  for  projecting  ear 

394-397.     Trautmann  operation  for  closure  of  posterior  deficiencies 

398-401.     The  von  Mosetig-Moorhoff  operation   for  posterior  deficiencies 

402-403.     Goldstein's  retro-auricular  plastic   

404.  Celluloid  artificial  ear 

405.  Incision  for  spino-facial  anastomosis   

406.  Spino-facial  and  peripbero-spinal  to  descendens  hypoglossi  anastomosis 

407.  Heck's  nerve  tracing  forceps   

408.  Facial-hypoglossal  end  to  side  anastomosis    

409      Facial-hypoglossal  end  to  end    anastomosis    


OPERATIVE  SURGERY  OF  THE  NOSE,  THROAT,  AND  EAR. 


CHAPTER     I. 
THE  SURGICAL  ANATOMY  OF  THE  XOSE  * 

By    Hanaii    \V.    Loch,   M.    I). 

External  Nose. 

The  external  nose  (nasus)  which  projects  downward  and  forward 
from  the  forehead,  between  the  eyes,  presents  two  lateral  and  one 
inferior  surface,  all  triangular  in  shape,  and  a  superior  surface  which 
varies  considerably  in  size  and  contour.  As  seen  in  Fi.ii's.  1  and  i!  the 
root  of  the  nose  (radix  nasi )  is  that  portion  projecting  for  a  short 
distance  downward  from  the  forehead,  and  the  bridge  of  the  nose 
(dorsnm  nasi)  is  the  superior  surface  extending  from  the  root  to  the 
tip  of  the  nose  (apex  nasi). 

The  supporting"  framework  of  the  nose  is  composed  of  bones  and 
cartilages,  united  by  connective  tissues.  It  is  lined  with  mucous  mem- 
brane and  covered  by  muscles  and  integument. 

The  nasal  bones  and  the  frontal  processes  ( processus  frontales 
maxilla?)  of  the  maxilla?  which  constitute  the  bony  framework  of  the 
external  nose  are  attached  by  strong  connective  tissue  fibres  to  the 
lateral  cartilages  (cartilagines  nasi  laterales)  at  the  apertura  piri- 
formis  (Figs.  1,  2,  9  and  11).  Each  of  these  cartilages  is  triangular  in 
shape  with  the  apex  downward,  and  is  attached  to  the  cartilage 
of  the  septum  (cartilage  septi  nasi),  and  to  its  fellow  on  the  oppo- 
site side.  A  variable  number  of  sesamoid  cartilages  (cartilagines 
sesamoidese)  are  found  between  the  lateral  nasal  cartilage  and  the 


*For  the  convenience  of  readers,  structures  are  designated  by  their  usual  English  names.  However, 
the  B.X.A.  nomenclature  is  given  in  the  text  and  exclusively  in  the  figures  in  order  to  follow  recognized 
authority  in  terminology. 

The  figures  accompanying  this  chapter  have  been  made  from  drawings  of  Mr.  Tom  .Tones,  with  the 
exception  of  Figs.  20  to  34,  inclusive.  Acknowledgment  is  gratefully  made  to  Dr.  I).  M.  Schoemaker  for 
the  dissections  illustrated  by  Figs.  1,  2  and  3.  The  remaining  preparations,  except  those  illustrated  by 
Figs.  9,  11  and  12,  were  made  by  the  author. 


Ol'KKATIVK    SUHCEHY    OF    THE    NOSE,    THROAT,    AND    EAR. 


RADIX     NASI 


PROCESSES 
FROMTALIS 


CARTILAGIN.ES 
ALARES      M INGRES 


TELA       SUBCUTA\L 


CARTILAGO 
NASI       LATERALIS 


CARTILAGO 
SESAMOIDEA 


CARTILAGO 
SEPTI      NASI 


CARTILAGO 
ALARIS     MAJOR 


APEX    NASI 


Fig.   1. 
Thf   cartilages  of  the   nose;    lateral    view. 


RADIX     NASI 


CARTILAGO     N/- 
LATERAL  IS 


C  ARTI  L/.  GO 
SF  PTI      •.!.  si 


-Ob       NASALE 


C ARTI LAGO 
bESAMOIDEA 


CARTILAGO     ALARIS 
MAJOR 


THK    SrWMCAI,    ANATOMY    OF    THK    NOSH.  ?, 

greater  alar  cartilage  (cartilago  alaris  major).  The.  lessar  alar  car- 
tilages (cartilagines  alarcs  minores)  arc  small  cartilaginous  plates, 
variable  in  iiuinl)er,  which  lie  between  the  greater  alar  cartilage  and 
the  maxilla. 

The  greater  alar  cartilage  (cartilago  alaris  major),  very  variable 
in  shape  and  extent,  constitutes  in  large  measure  the  framework  of 
the  lower  lateral  portion  of  the  external  nose,  and  that  of  the  ala 
(cms  laterale).  The  medial  portion  (cms  medialc)  (Fig.  .'»)  winds 
around  the  anterior  inferior  portion  giving  to  the  naris  its  rounded 
appearance.  It  is  loosely  connected  with  the  cartilage  of  the  septum. 
A  mass  of  connective  tissues  lies  behind  and  below  the  .u-reater  alar 
cartilage  forming  a  considerable  portion  of  the  ala  (tola  snbciitanea  ). 


CRUS     MEDIALE 


CARTILAGO         / 
SEPTI      NASI 


VESTIBULUM 


The  orifices  of  the  nose  showing  a  dissection   of  the  crura   inedialia   of 
the    cartilagines    alares    majores. 

Nasal  Cavities. 

The  anterior  portion  of  the  nasal  cavities,  between  the  ala  and  the 
septum,  is  called  the  vestibule  (Figs.  .'>,  (5  and  7).  It  is  covered  with 
squamous  epithelium  and  contains  numerous  stiff  hairs  known  as 
vibrissse. 

The  nasal  cavities,  right  and  left,  are  hollow  spaces  between  the 
bones  of  the  head  and  face,  extending  backward  from  the  vestibule  to 
the  nasopharynx,  and  from  the  floor  of  the  cranial  cavity  above  to  the 
roof  of  the  mouth  below. 

Floor  of  the  Nose. — The  bony  floor,  narrowest  at  its  anterior 
extremity,  becoming  wider  posteriorly  and  then  narrower  at  the 
choanae,  is  formed  by  the  palatal  process  of  the  maxilla  (processus 
palatinus  ossis  maxillaris)  and  the  palatal  process  of  the  palate  bone 
(processus  horizontals  ossis  palatini).  The  suture  between  these 
bones  divides  the  floor  into  two  unequal  portions,  the  anterior  three- 
fourths  approximately  being  maxilla  and  the  posterior  one-fourth 


4  OPERATIVE    STHfiKHV    OF    THE    NOSE,    THKOAT,    AND    EAR. 

palate  bone.  (  Fig.  4.)  The  eanalis  incisivus  which  opens  on  the 
septum  just  above,  ])enetrates  the  floor  in  its  anterior  portion  convey- 
ing the  nasopalatine  nerve  and  artery  to  tlie  roof  of  the  mouth.  The 
sinus  maxillaris  may  he  seen  external  to  the  lateral  wall  of  the  nose 
extending  below  the  level  of  the  Moor.  (See  also  Fig.  1.'!.) 

Septum  Nasi. — The  septum  nasi  forms  the  inner  wall  of  each  nasal 
cavity,  approximately  in  the  median  line.  It  may  be  straight,  but 
more  often  it  is  bent  to  one  side  or  the  other  or  irregularly  deviated 
in  one  or  both  nares.  It  is  divided  into  three  parts,  the  bony  (septum 
nasi  osseum),  cartilaginous  (cartilagineum)  and  membranous  (mem- 
branaceum)  septum  (Fig.  5).  The  membranous  portion  (septum  mobile 
nasi)  separates  the  vestibule  from  its  fellow,  and  is  made  up  of  the 


SUTURA 
PALATIN  A 
TKANSVERSA 


PARS 
HORIZONTALS 


SINUS 
MAXILLARIS 


•'•• 
'•'  °-|'.V-L' 


•  NW 

CANALIS    INCISIVUS 


PROCESSUb 
PALATINUS 


SPINA     NASALIS    ANTERIOR 


FiS.    4. 
Floor   of   the   nose. 


ernra  medialia  of  the  two  greater  alar  cartilages,  with  their  attach- 
ments to  the  septum  nasi,  covered  by  a  mucocutaneous  investment.  'Die 
cartilaginous  portion  (septum  cartilagineum)  is  formed  by  the 
cartilage  of  the  septum  and  the  cartilage  of  Jacobson.  The  cartilage 
of  the  septum  is  more  or  less  quadrilateral  in  form  and  is  attached 
posterosuperiorly  to  the  perpendicular  plate  of  the  ethmoid  (lamina 
perpendieularis  ossis  etlimoidalis),  posteroinferiorly  to  the  groove  ol 
t!ie  vomer,  inferiorly  to  the  anterior  part  of  the  crista  nasalis  maxilla; 
and  to  Jacobson 's  cartilage,  and  superiorly  to  the  nasal  bones  and  the 
lateral  cartilages.  From  the  posterior  angle  a  projection  extends  back- 
ward often  for  some  distance,  known  as  the  processus  sphenoidalis 
scpti  cartila.innei.  Jacobson  V  cartilage  (cartilage  vomeronasalis 


T11K    SrUlilCAL    AXATO.MV    OK    TIIK     NOSK.  f) 

Jacobsoni)  lies  between  the  cartilage  and  the  voinei1,  and  the  nasal 
crest  of  the  maxilla. 

The  bony  portion  is  composed  of  the  perpendicular  plate  of  the 
ethmoid,  the  rostrum  of  the  sphenoid  (crista  sphenoidalis),  the  vonier, 
the  maxillary  crest  (crista  nasalis  maxilla1),  aixl  the  palatine  crest 
(crista  nasalis  ossis  palatini). 

The  perpendicular  plate  of  the  ethmoid  extends  downward  and 
forward  from  the  cribriform  plate  of  the  ethmoid  (lamina  cribrosa  ossis 


LAMIN  ^ 
PERPENDICULAR! 


OS      FRONTALE 


LAMINA 
CRIBROSA 


CRISTA 

SPHENOIDALIS 


SINUS 
SPHENOIDALI 


CARTILAGO      NASI 
LATERALIS 


CARTILAGO 
SEPTI     NASI 


CARTILAGO 
ALARIS     MAJOR 


SPINA' 

NASALIS 

POSTERIOR 


SEPTUM 
MOBILE       NASI 


CARTILAGO 

VOMERONASALIS 

I  JACOBSONH 


SPINA     NASALIS 
ANTERIOR 


CRISTA      NASALIS         CRISTA      NASALIS 
OSSIS      PALATINI  MAXILLXE 


PROCESSUS 

PALATINUS         CANALIS    INCISIVUS 


Fig.  5. 
The   septum    nasi. 


ethmoidalis)  having  attachments  with  the  nasal  spine  (spina  nasalis) 
of  the  frontal,  the  nasal  bones,  the  cartilages  of  the  septum,  the  vomer 
and  the  rostrum  of  the  sphenoid. 

The  vomer  constitutes  practically  the  whole  of  the  posterior  and 
inferior  part  of  the  septum,  articulating  below  with  the  nasal  crest 
of  the  maxillary  and  palate  bones,  anteriorly  and  superiorly  with  the 
cartilage  of  the  septum,  Jacobson's  cartilage  and  the  perpendicular 
plate  of  the  ethmoid,  and  superiorly  with  the  rostrum  and  body  of  the 


6 


OPERATIVE  SUR<;ERV  OF  THE  NOSE,  THROAT,  AXD  EAR. 


sphenoid.  Its  superior  margin  divides  into  two  wings,  alae  vomeris, 
by  which  it  is  attached  to  the  sphenoid.  The  posterior  border  forms 
the  dividing  boundary  of  the  two  choanae  or  posterior  nares.  (Fig.  8.) 

The  rostrum  of  the  sphenoid  takes  part  in  the  formation  of  the 
septum.  In  the  specimen  illustrated  (Fig.  5)  it  is  triangular  and 
considerably  larger  than  usual. 

The  maxilla  furnishes  but  a  small  part  of  the  nasal  septum,  the 


SINUS      FRONTALIS 

AGGER      NASI 

CRISTA      GALLI 


CONCHA       NASALIS      MEDIA 


RECESSUS 

SPHENOETHMOIDALIS 


VtSTIBULUM 


LABIUM       SUPERIUS 


'    OSTIUM 

PHA'RYNGEUM    rue/t 


NASI       SUPERIOR 
MEATUS      NASI      MEDIUS 


PARS      HORIZONTALS 
1        CONCHA      NASALIS      INFERIOR 

MEATUS       NASI       INFERIOR 

Fig.  6. 
The  outer   wall   of  the   right   nasal   cavity. 


crista  nasalis,  which  by  its  articulation  with  the  vomer,  Jacobson's 
cartilage,  and  the  cartilage  of  the  septum,  comprises  the  inferior  portion 
of  the  septum,  corresponding  to  the  extent  of  the  maxillary  portion  of 
The  floor.  In  its  anterior  half  it  presents  the  canalis  incisivus  for  the 
passage  of  the  nasopalatine  nerve  and  artery.  Its  most  anterior  pro- 


THE    SURGICAL    ANATOMY    OF    TliK    NOSH.  i 

jection  is  tlio  anterior  nasal   spine   (spina   nasalis  anterior).     (Figs.  4 
and  5.) 

Corresponding  with  the  nasal  crest  of  the  maxillary  is  a  similar 
projection  upward  from  the  horizontal  plate  of  the  palate  bone.  It 
lies  behind  the  nasal  crest  of  the  maxillary  and  articulates  with  it  at 
the  sutura  palatina  transversa.  Posteriorly  it  presents  the  posterior 
spine  (spina  nasalis  posterior). 

Roof  of  the  Nose. — The  roof  of  the  nose  is  constituted  from  before 
backward  by  the  following  bones:  the  nasal,  the  frontal,  the  ethmoid 
and  sphenoid.  The  lamina  cribrosa  of  the  ethmoid  (Figs,  5,  \'2,  45,  4b', 
48,  50,  53,  54  and  55)  which  conveys  the  filaments  of  the  olfactory  nerve 
(Figs.  44  and  47)  from  the  cranial  cavity  into  the  nasal  cavity  is  almost 
horizontal.  It  is  composed  of  very  hard  bone  which  is  easily  recog- 
nized by  the  operator  on  account  of  its  resistance  to  the  instrument. 
The  sphenoid  ordinarily  constitutes  but  a  small  part  of  the  roof  of 
the  nose  just  behind  the  ethmoid,  likewise  the  frontal  which  lies  just 
anterior  to  the  ethmoid.  Anterior  to  the  sphenoid  in  the  angle  between 
it  and  the  ethmoid,  there  is  a  space  called  the  recessus  sphenoethmoid- 
alis,  which  receives  the  opening  of  the  sphenoid  sinus. 

A  probe  with  its  end  tipped  slightly  downward  will  readily  enter 
the  sphenoid  if  it  is  passed  backward  about  7  cm.  along  the  roof  to 
the  recessus  sphenoethmoidalis.  As  a  rule  to  accomplish  this,  it  is 
necessary  to  resect  the  middle  turbinate.  Figs.  6  and  7  show  very 
clearly  the  possibility  of  using  this  method. 

External  Wall  of  the  Nose. — The  maxilla  and  palate  which  are 
united  vertically,  with  their  attachments,  the  inferior  turbinate  (con- 
cha nasalis  inferior),  lacrimal,  ethmoid  and  sphenoid,  constitute  the 
outer  wall  of  the  nose.  The  inferior  turbinate  and  the  middle  tur- 
binate (concha  nasalis  media)  (Figs.  6,  7,  15,  16,  17  and  18)  are 
attached  to  the  crista  conchalis  and  crista  turbinalis  of  the 
maxilla  and  of  the  palate  bone.  The  superior  turbinate  (concha 
nasalis  superior)  and  supreme  turbinate  (concha  nasalis  suprema), 
which  is  present  in  about  one-third  of  the  cases,  run  parallel  to  the 
middle  turbinate,  but  are  continuous  with  the  lateral  mass  of  the 
ethmoid  from  which  they  project  backward  for  a  short  distance.  The 
inferior  turbinate  and  middle  turbinate  extend  about  the  same  dis- 
tances forward,  constituting  by  far  the  greater  portion  of  the  projection 
from  the  external  wall.  A  line  drawn  along  the  superior  border  of  the 
middle  turbinate  and  extended  to  the  anterior  wall  divides  the  nose 
into  two  unequal  parts,  a  superior  comprising1  about  one-fifth  and  an 
inferior  about  four-fifths.  The  superior  and  supremo  turbinates  are 
much  smaller  and  shorter  than  the  other  turbinates.  They  spring  from 


8  OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

the  lateral  mass  of  the  ethmoid  in  the  posterior  third  of  the  nasal  wall. 
However,  all  of  the  tiirbinates  extend  about  the  same  distance  backward. 
The  choana?  therefore  are  in  relation  with  the  posterior  ends  of  the 
inferior  and  middle  tiirbinates.  (See  Fig'.  8.)  The  superior  and 
supreme  tnrbinate  lie  just  above  the  superior  choanal  level.  Upon 
examination  through  the  anterior  naves,  the  inferior  is  visible  for  from 
one-half  to  its  whole  length,  the  middle  ordinarily  at  its  anterior  end, 


OSTIUM      CELLULXE  BULL 

ETHMOIDALIS     ANTERIORIS  ETHMOIDALIS 


OSTIA       CELLULARUM 
ETHMOIDALIUM       POSTERIORUM 


COMCHA       NASALIS      SUPERIOR      ' 
RECESSUS    SPHENOETHMOIDALIS 
APERTURA      SINUS     SPHENOIDALIS 

SINUS      SPHENOIDALIS 


CONCHA 
NASALIS      MEDIA 


SINUS      FRONTALIS 


CONCHA      NASALIS      MEDIA 


INFUNDIBULUM 
ETHMOIDALE 


HIATUS 
SEMILUNARIS 


VESTIBULUM 


OSTIUM       PHARYNGEUM       TUBXE 


LABIUM 
,        SUPERIUS 


CONCHA      NASALIS      INFERIOR 


Fig.   7. 
The  outer  wall  <»'  the  left   nasal  cavity   with   the  concha  media  reinov 


and  the  superior  and  supreme  are  not  visible  unless  extensive  atrophy 
i-  present  oi'  unless  the  middle  tnrbinate  has  been  removed. 

The  inferior  tnrbinate  is  attached  to  the  biennial,  const  it  ill  ing  a 
portion  of  the  wall  of  the  nasolacrimal  canal,  and  to  the  ethmoid;  it 
serves  to  decrease  the  si/e  of  the  orifice  of  the  maxillary  sinus. 

The  tiirbinates  are  covered  with  mucous  membrane,  continuous 
with  the  mucous  membrane  of  the  external  wall  of  the  nose.  It  is 


T1IK    SUKIiK'AL    ANATOMY    OK    T1IK    NOSK. 


9 


thickest  over  the  inferior  and  middle  turhinates,  made  so  by  the  large 
number  of  venous  radicles  which  are  present.  These  have  been  variously 
designated  as  turbinate  bodies,  Sehwellkorper  (by  /uckcrkandl) 
(plexus  cavernosi  conch  arum );  they  are  of  great  imporlance  in  the 


APERTURA       SINUS     SPHENOIDALIS 


NERVUS 
TROCHLEARIS 


NERVUS      OPTICUS 


NERVUS 
OPHTHALMICUS 


CONCHA 

NASALIS 

SUPERIOR 


MUSCULUS 
PTERYGOIOEU? 

INTERNUS. 


Fig.  8. 
The  choans  and  anterior  wall  of  the  sphenoid  sinus  viewed  from  behind. 

physiologic  action  of  the  nose,  more  particularly  in  connection   with 
respiration. 

There  is  a  small  elevation  on  the  outer  wall  just  anterior  to  the 
middle  turbinate  known  as  the  agger  nasi.  It  is  sometimes  the  seat  of 
an  anterior  ethmoid  cell.  It  is  by  entering  through  the  (niter  wall  at 
the  agger  uasi  that  Mosher  recommends  that  the  ethmoid  cells  be 
curetted  without  disturbing  or  necessarily  removing  the  middle  tur- 


10  OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

binate  bone.  Below  this  is  a  slight  depression  known  as  atrium  meatus 
medii,  which  extends  backward  and  downward  into  the  middle  meatus. 

By  virtue  of  the  turbinate  ledges  on  the  external  wall,  the  nasal 
cavity  is  divided  into  three  meatuses,  the  inferior,  middle  and 
superior  (Figs.  6,  13,  17  and  18). 

The  inferior  meatus,  below  and  lateral  to  the  inferior  turbinate 
bone,  receives  the  lacrimal  secretion  through  the  orifice  of  the  naso- 
lacrimal  duct,  in  its  anterosuperior  portion.  None  of  the  accessory 
sinuses  opens  into  it. 

The  middle  meatus  contains  the  orifices  of  the  frontal  and 
maxillary  sinuses,  and  of  the  anterior  ethmoid  cells.  These  orifices  in 
the  main  open  into  the  infundibulum,  a  hollowed  out  space  below  the 
maxillary  attachment  of  the  middle  turbinate  and  between  the  bulla 
ethmoidalis  and  the  uncinate  process  of  the  ethmoid  bone  (Figs.  7  and 
13).  The  frontal  and  one  or  more  of  the  anterior  ethmoidal  cells  open 
usually  through  its  anterior  and  upper  portion. 

The  maxillary  sinus  opens  as  a  rule  posterior  to  the  orifice  of  the 
frontal  sinus.  It  not  infrequently  lies  in  such  a  position  that  discharge 
from  the  frontal  and  ethmoid  cells  passes  directly  through  the  in- 
fundibulum into  the  maxillary  sinus.  The  opening  of  the  maxillary 
is  not  always  single;  one  or  more  accessory  orifices  may  be  present, 
but  they  open  into  the  middle  meatus.  The  infundibulum  communi- 
cates with  the  middle  meatus  through  the  hiatus  semilunaris. 

The  superior  meatus  contains  the  openings  of  most  of  the  posterior 
ethmoid  cells.  Occasionally  one  is  found  above  the  superior  turbinate. 
Behind  and  above  this  is  the  opening  of  the  sphenoid  in  the  spheno- 
ethmoidal  recess. 

The  Choanae  or  posterior  nares  which  are  the  openings 
of  the  nose  into  the  nasopharynx  are  oval  shaped  and  fairly  sym- 
metrical. They  are  formed  by  the  vomer  internally,  the  horizontal 
plate  of  the  palate  inferiorly,  the  vomer  and  sphenoid  superiorly,  and 
externally  by  the  processus  pterygoideus. 

Fig.  8  is  an  illustration  of  the  choana*  from  behind  with  the 
inferior  portion  of  the  anterior  wall  of  the  sphenoid  sinus  cut  away 
so  as  to  show  the  nasal  cavity  projecting  above  the  upper  level  of 
the  clioawr.  It  also  serves  to  show  the  relation  of  the  sphenoid 
sinuses  to  the  choana',  the  nasal  cavities,  and  the  optic  nerve. 

Posterior  to  the  choana'  on  each  lateral  wall  of  the  pharynx  is 
the  opening  of  the  Fiislachiaii  tube.  In  children  the  nasal  cavities 
are  relatively  -mailer  than  in  adults  for  the  reason  that  the  turbinatcs 
are  far  larger  in  proportion. 


THK    Sl"I{<;K'AL    ANATOMY'    OF    'I  1 1  K     XOSK. 


1! 


Accessory  Sinuses  of  the  Nose. 

The  accessory  sinuses  of  the  nose  are  cavities  in  the  maxillary. 
frontal,  ethmoid  and  sphenoid  bones,  which  are  lined  with  a  niucosa 
continuous  with  that  of  the  nose;  they  communicate  with  the  nasal 
cavities  in  places  more  or  less  definite. 

In  order  to  understand  their  different  relations,  it  is  advisable  to 
study  the  bones  which  form  their  walls. 


FORAMEN        ETHMOIDALE 
SINUS      FRONTALIS  ANTERIUS 


CELLUL>E      ETHMOIOALES 
ANTERIORES 


OS     FRONTALE 

SUTURA      INTERNASALIS 


FORAMEN       ETHMOIDALE 
POSTERIUS 


FORAMEN      OPTICUM 


FISSURA      ORBITALIS 
SUPERIOR 


SEPTUM      NARIUM 
OSSEUM 


APERTURA      PIRIFORMIS 


CRISTA      LACRIMALIS 
ANTERIOR 


CRISTA      LACRIMALIS 
POSTERIOR 

FORAMEN 
INFRAORBITALE 


FISSURA      ORBITALIS 
INFERIOR 


SULCUS      IMFRAORBITALIS 
;     SINUS      SPHENOIDALIS 
CELLULA       ETHMOIDALIS      POSTERIOR 


Fig.   9. 
The  left  orbit:    bone  relations. 


The  two  nasal  bones  united  at  the  sutura  internasalis  and  the 
two  maxillary  bones  united  at  the  sutura  intennaxillaris.  together 
with  the  corresponding  nasal  bones  at  the  sutura  nasomaxillaris  form 
the  apertura  piriformis,  or  the  entrance  to  the  bony  nose  to  which  the 
soft  parts  of  the  external  nose  are  attached  (Fiirs.  1)  and  11  ).  The  nasal 
bones  above  form  the  portion  of  the  roof  of  the  nose  which  lies  anterior 


12 


OPERATIVE    STRtJERY    OF    THE    NOSE,    THROAT,    AND    EAR. 


to  the  frontal  with  which  they  articulate  at  the  nasofrontal  suture. 
The  maxilla  constitutes  the  anterior,  external  and  posterior  Avails  of 
the  sinus  maxillaris  which  it  encloses.  It  articulates  externally  with 
the  malar  (os  zygomaticum)  at  the  sutura  zygomaticomaxillaris.  It 
is  extended  into  the  orbit  and  assists  in  forming  its  floor  by  articulating 
with  the  lacrimal,  ethmoid  and  sphenoid  bones.  In  the  orbit,  as  shown 


SINUS      FRONTALIS 


CELLUL/E      ETHMCIDALES 
,ANTERIORES 


CELLULES      ETHMOIDALES 
POSTERIORES 


NERVUS      OPTICUS 


SINUS      SPHENOIDALIS 


OS       ZYGOMATICUM 


SINUS     MAXILLARIS 


Fit;,    in. 
Left    orbit    with    bone    removed    exposing    the    inucosa    of    the    accessory    sinuses. 


in  Fiir.  !',  the  sinuses  are  visible  where  the  bone  has  been  cut  away, 
the  ethmoid  in  the  biennial  and  ethmoid  bones,  the  frontal  in  the 
frontal  bone,  and  the  sphenoid  in  the  sphenoid  bone.  A  realistic  view 
of  the  sinuses  is  seen  in  Fig.  10,  in  which  the  decalcified  bone  in  tin; 
specimen  illustrated  has  been  removed  leaving  the  mucosa  of  the 
sinuses  intact,  the  frontal,  anterior  and  posterior  ethmoid  and  the 
sphenoid,  from  before  backward,  and  the  maxillary  below.  From  these 


THK    St'KCK'AL    ANATO.MV    OK    T  1 1  K     NOSK. 


figures  it  is  easy  to  observe  how  an  inflammation  of  the  ethmoid  cell- 
may  result  in  a  periorbital  abscess. 

In  Fig.  11,  the  outer  plate  and  cancellous  tissue  over  the  frontal 
sinuses  have  been  cut  away  leaving  the  sinuses  free  with  a  thin  cover- 
ing of  bone.  The  sinuses  are  somewhat  larger  than  the  average,  but 
their  relation  to  the  adjacent  bone  structure  is  well  shown. 


OS   NASALE 


FORAMEN   SUPRAORBITALE 


FORAMEN   SUPRAORBITALE 


CRISTA 
LACRIM  ALIS 
POSTERIOR 


CRISTA 

LACRIMALIS 

ANTERIOR 


PI  Rl  FORM  IS 


FISSURA 
CRQITALIS 
SUPERIOR 


FISSLRA 
O  R  3  I  T  A  L  I  S 
INFERIOR 

F'ROCESSUS      FRONTALIS 

APERTURA       PI  R  I  FORM  IS 
SEPTUM  SPI\A 

NARIUM  NASALIS 

OSSEUM       ANTERIOR     CONCHA      NASALIS      INFERIOR 


Fig.  11. 
Bones  of  the   nose  and   orbits:    external    plate   over   frontal    simisrs    removed. 

The  roof  of  the  nose  and  of  the  orbits  from  the  endocranial  side 
is  presented  in  Fig.  12.  The  relations  of  sinuses  to  the  lesser  wing 
of  tbe  sphenoid  bone,  the  pituitary  fossa  (fossa  hypophyseos),  the 
optic  chiasm,  the  frontal,  and  the  cribriform  plate  of  the  ethmoid  bone 
are  shown.  The  frontal  sinuses,  anterior  and  posterior  ethmoid  cells 
and  sphenoid  sinuses  are  shown  in  succession. 


14 


OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 


A  clearer  understanding  of  the  cells  from  this  aspect  may  be 
secured  from  Fig.  52,  which  is  made  from  a  specimen  which  was  pre- 
pared after  decalcification  by  removing  the  endocranial  bone  covering 
from  the  sinuses,  leaving  the  mucosa  intact.  The  relation  of  the  optic 
nerve  to  the  two  sphenoid  sinuses  and  to  the  last  posterior  ethmoid 
cell  is  well  brought  out  in  this  illustration. 

Frontal  Sinus. — The  frontal  sinus  is  the  most  anteriorly  placed  of 


CRISTA      GALLI  FORAMEN     CXECUM 


SINUS      FRONTALIS 


SINUS      FRONTALIS 


CORPUS      CSSIS 
SPHE  \OIDALIS 

PROCESfrL  S 

CLI\OIDE  L  S 

ANTERIOR 


CE1_LL  L  A 
ETHMOlDALIS 

ANTERIOR 


CELLULA 
ETHT.'OIDALIS 
POSTERIORIS 

SIMJS    SPHENOIDALIS 


CRIDROSA 


PROLESSUS 
Ci-lNOi  DEL'S       POSTERIOR 


FOSSA       HYPOPHYSEOS 


SULCUS 

C  MIASMATIC  US 


Fig.   12. 
Floor    of   the    anterior    cranial    fossa;    bony    roof    of   accessory    sinus    removed    in    part. 


all  the  accessory  sinuses  of  tin-  nose.  Il  varies  ureatly  in  si/e,  but 
conforms  in  some  measure  to  a  uniform  plan  in  that  the  si/e  laterally 
depends  upon  how  many  recesses  more  or  less  resembling  one  another 
are  present.  Thus  there  may  be  one,  1  wo,  three  or  even  four  of  these 
]•(.(•  esses  present.  The  frontal  sinus  lies  between  the  two  plates  of  the 
frontal  hone.  Its  anterior  wall  forms  the  prominence  of  the  forehead 


T11K    SUIKJICAL    ANATOMY    OF    TIIK    NOSE. 


15 


above  the  eyebrows.  (See  Fig.  11.)  The  posterior  and  superior  wall 
separates  it  from  the  frontal  lobe  of  the  brain,  the  inferior  from  the 
orbit.  The  irregularities  in  the  anterior  wall  are  well  shown  in  this 
figure,  as  well  as  the  relation  to  the  orbit  and  the  foramen  supraor- 


CRISTA      GALLI 


SINUS      FRONTALIS 


BULLA 
ETHMOIDAL1S 


MEATUS 

NASI 
TNFERIOR 


CELLULA 

ETHMOIDAL1S 

ANTERIOR 


BULLA 
ETHMOIDALIS 


PROCESSUS 

UNCINATUS 


OSTIUM 
_  -    SINUS 
MAXILLARJS 


CONCHA 

"NASALIS 
MEDIA 


SINUS 
MAXILLARIS 


CONCHA      NASALIS      INFERIOR 


PROCESSUS      PALATINUS 
SEPTUM      NASI 


Fig.  13. 
Coronal  section  through  the  nose  and  orbit. 

bitale.     Radiographs  show  the  extent  and  shape  of  this  wall  and  are 

therefore  required  before  radical  operative  procedures  are  undertaken. 

The  relation  of  the  posterior  and  superior  wall  to  the  brain  lias 

been  studied  extensively  by  Onodi,  who  found  that  this  wall  of  the 


16  OPERATIVP:  SUROERY  OF  THE  XOSE,  THROAT,  AND  EAR. 

frontal  sinus  may  extend  over  the  gyms  frontalis  superior,  gyms 
frontalis  medius  and  gyms  frontalis  inferior.  The  inferior  wall  is  in 
relation  with  the  orbit  (Fig.  13)  and  reaches  often  far  back  into  the 
ethmoid  labyrinth.  As  a  rule  it  extends  but  a  short  distance  pos- 
teriorly over  the  orbit  while  laterally  it  is  usually  limited  to  the  inner 
and  middle  thirds,  although  in  some  instances  it  may  reach  the  outer 
third.  The  septum  between  the  two  frontals  is  seldom  directly  in  the 
median  line,  on  which  account  either  sinus  may  extend  beyond  it. 
The  cavity  is  often  subdivided  by  more  or  less  complete  septa  which 
have  the  effect  of  establishing  pockets  in  what  would  be  otherwise  a 
smooth  cavity.  Fig.  11  shows  how  irregular  it  may  be.  The  sinus 
opens  into  the  middle  meatus  by  way  of  the  infundibulum  through 
an  elongated  canal  (Figs.  7,  15,  16,  17  and  18)  or  simply  as  a  foramen 
directly  into  the  infundibulum.  A  very  characteristic  formation  of  the 
upper  portion  of  the  infundibulum  is  shown  in  Figs.  If)  and  16,  in  which 
it  lies  behind  an  anterior  ethmoidal  cell,  quite  similar  in  appearance. 
In  Fig.  16,  the  frontal  is  seen  opening  into  the  infundibulum  through 
a  canal.  There  has  been  considerable  confusion  in  the  application  of 
the  terms  infundibulum  and  hiatus  semilnnaris.  Onodi  includes  under 
the  term  hiatus  semilunaris,  the  entire  space  between  the  nncinate 
process  and  the  bulla  ethmoidalis  of  the  ethmoid  bone,  and  accepts  the 
designation  of  Killian,  recessus  frontalis,  for  the  sharply  outlined  fossa 
into  which  the  frontal  often  opens.  Where  a  canal  is  present,  he  terms 
it  ductus  nasofrontalis.  It  is  quite  common  for  one  or  more  ethmoid 
cells  to  open  with  the  frontal  through  the  infundibulum,  furthermore  the 
orifice  of  the  maxillary  sinus  may  lie  in  such  a  position  that  it  receives 
the  pus  which  Hows  from  the  frontal  sinus  and  ethmoid  cells,  giving 
the  impression  that  suppuration  of  the  maxillary  sinus  is  present. 

Maxillary  Sinus. — The  maxillary  sinus  as  will  be  seen  in  Fig.  14, 
is  a  cavity  in  the  maxilla  interposed  between  the  alveolar  process  and 
the  orbit  and  the  external  wall  of  the  nose  and  the  malar  process.  A 
portion  of  the  anterior  wall  has  been  cut  away  bringing  the  cavity  into 
view.  That  portion  of  the  alveolar  process  covering  the  roots  of  the 
teeth  has  been  cut  away,  to  show  their  relation  to  the  floor  of  the 
sinus.  In  the  specimen  illustrated  the  roots  of  the  three  molai>  and 
two  bicuspids  are  in  dose  relation  with  the  sinus,  two  of  the  roots  of 
the  second  molar  making  indentations  into  the  floor.  The  cuspid 
lies  anterior  to  the  sinus,  but  it  extends  above  the  floor. 

The  floor  of  the  sinus  is  by  no  means  smooth  or  regular;  as  a  rule 
there  are  bony  septa  present  which  divide  it  into  pockets.  Hence 
puncture  through  the  alveolus  will  not  necessarily  result  in  satis- 
factory drainage.  The  floor  of  the  nose  is  generally  on  a  higher  level 
than  that  of  the  sinus.  (See  Fiirs.  4  and  1.".. ) 


TIIK    SfllCICAL    ANATOMY    OF    TIIK     NOSK. 


1 


The  posterior  limit  of  the  maxilla  separates  the  maxillary  sinus 
from  the  zygomatic  fossa  (fossa  infratemporalis).  The  Hour  of 
the  orbit  in  part  constitutes  the  roof  of  the  sinus  and  the  external 
wall  of  the  nose,  its  internal  wall.  The  canal  for  the  infraorhital  nerve 
forms  in  most  instances  a  ridge  on  the  roof  of  the  sinus;  however,  the 
ridge  may  not  be  well  marked  and  may  be  even  absent.  (Fig.  !..'>.) 

The  opening  of  the  sinus  into  the  middle  meatus  is  on  the  internal 
wall,  generally  in  its  upper  part;  at  times  there  are  accessor}'  openings. 


LAMINA       PAPYRACEA        ,' 


OS      ZYGOMATICUM 


FOSSA         

INFRATEMPORALIS 


"• 


Fig.   14. 

Right  lateral  view  of  bones  of  the  face   with  maxillary  sinus  and  roots 
of  the  teeth  exposed. 


Hence  it  is  that  pus  in  this  sinus  is  evacuated  through  its  openin; 
readily  in  the  recumbent  position;  pus  coining  from  the  middle  meatus 
may  be  determined  to  come  from  the  maxillary  sinus  if  it  appears  or 
increases  when  the  head  is  lowered  and  the  face  is  turned  towards  the 
side  examined.  This  brings  the  orifice  into  the  most  dependent  position 
and  thus  permits  pus  to  How  out  more  readily.  The  position  is  not 
conducive  to  the  flow  of  pus  from  the  frontal  sinus  or  the  anterior 
ethmoid  cells. 


18 


OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 


The  maxillary  sinus  may  bo  opened  surgically: 

1.  Through  the  alveolar  process  by  removing-  a  tooth  or  in  some 
instances  without  the  removal  of  a  tooth. 

2.  Through  the  anterior  wall  (in  the  fossa  canina)  in  the  mouth. 

3.  In  the  middle  or  inferior  meatus,  with  or  without  resecting  a 
part  of  the  inferior  turbinate. 

4.  By  cutting  away  a  part  of  the  margin  of  the  apertura  piri- 
formis  through  the  nose  and  continuing  the  excision  by  removing  a 


SINUS    .. 
FRONTALIS 


CELLULA    

ETHMOIDALIS 
ANTERIOR 


MEATUS     -- 
NASI       MEDIUS 


CANALIS'' 
NASOLACRIMALIS 


INFUNDIBULUM       ETHMOIDALE 

CELLUL/E      ETHMOIDALES      ANTERIORES 


CELLULA       ETHMOIDALIS       POSTERIOR 
'  CELLULA 

/       ETHMOIDALIS       POSTERIOR 

SINUS      SPHENOIDALIS 


SINUS 
SPHENOIDALIS 


FOSSA 
PTERYGOPALATINA 


PTERYGOIDEA 


SINUS 
MAXILLARIS 


Fig.  15. 

Sagittal    section    through    the   right    side   of   nose   and    maxillary    sinus. 
External    portion. 


part  of  the  external  wall  of  the  nose  below  the  attachment  of  the 
inferior  turbinate  (Canfiold's  operation). 

Ethmoid  Cells. — The  ethmoid  cells  are  divided  into  two  groups, 
the  anterior  which  open  into  the  middle  meatus  and  the  posterior  which 
open  above  the  middle  turbinate,  generally  in  the  superior  meatus. 

There  is  no  uniformity  as  to  the  number,  position  or  sixe  of  the 
cells  in  either  group.  They  lie  in  the  bony  wall  between  the  nasal 
cavities  and  the  orbit,  the  frontal  and  sphenoid  sinuses,  and  between 
the  floor  of  the  cranial  cavitv  and  the  middle  turbinate. 


THE    SUHCICAL    ANATOMY    OF    TIIK    NOSK. 


1!) 


Sometimes  an  ethmoid  cell  may  extend  into  the  middle  turbinatc 
forming1  what  is  known  as  a  concha  hnllosa.  Such  a  cell  as  a  rule 
has  it  opening  in  its  upper  part,  and  therefore  drainage  is  unsatis- 
factory when  any  affection  is  present  which  causes  it  to  fill  up  with 
fluid.  The  bulla  ethmoidalis  (Figs.  7  and  ].'{)  contains  one  or  more 
ethmoid  cells,  generally  belonging  to  the  anterior  group,  although  occa- 
sionally one  is  found  opening  into  the  superior  nieatns. 

In  the  specimens  illustrated  in  Figs.  15  and  1(5,  a  sagittal  section 
has  been  made,  so  as  to  cut  through  the  anterior  attachment  of  the 


INFUNDIBULUM       ETHMOIOALE 
CELLULA       ETHMOIDALIS      ANTERIOR      [ 


CELLUL/E     ETHMOIDALES     POSTERIORES 

CELLULA 

ETHMOIDALIS       POSTERIOR 


SINUS 
SPHENOIDALIS 


SINUS 
SPHENOIDALIS 


FOSSA,,  -  ' 
PTERYGOPALATINA 


CANALIS 
PTERYGOPALATINUS 


SINUS 
FRONTALIS 


CELLULA 

ETHMOIDALIS 

ANTERIOR 


CONCHA 

-     NASALIS 

MEDIA 


*v        SPIN  A 
OS      PALATINUM  ^_—_  NASALIS    ANTER.OR 

PROCESSUS      UNCINATUS      / 

CONCHA     NASALIS     INFERIOR 

Fig.  16. 
Sagittal   section   through   the   right  side   of   the   nose.     Internal   portion. 


inferior  tnrbinate  to  the  maxilla,  which  is  shown  free  except  for  its 
attachment  to  the  palate  bone.  The  middle  tnrbinate  is  shown  articu- 
lated with  both  the  maxilla  and  palate  bone.  The  micinate  process 
which  assists  in  closing  up  the  inner  wall  of  the  maxillary  sinus 
projects  downward  from  the  lateral  mass  of  the  ethmoid.  As  will 
be  noted  it  partakes  in  part  of  the  general  celhilar  arrangement  of  the 
bone  in  this  position. 

The  frontal  opening  into  the  infundibulum  ethmoidale  is  well  shown 


20 


OPERATIVE    SURfiEHV    OF    THE    NOSE,    THROAT,    AND    EAR. 


while  adjacent  anterior  etlimoidal  cells  are  quite  typical.     Behind  these 
are  the  posterior  ethmoid  cells,  and  posterior  to  them,  the  sphenoid. 

The  specimen  shows  the  pterygomaxillary  canal  throughout  its 
entire  extent.  It  will  be  observed  that  the  upper  part  of  the  canal, 
where  the  sphenopalatine  ganglion  lies,  may  be  entered  by  plunging 


SINUS      FRONTALIS 


INFUNDIBULUM       ETHMOIDALE 


IS      ANTERIOR 


CELLULXE      ETHMOIDALES      POSTERIORES 

^ 

SINUS      SPHENOIDALIS      DEXTER 


SINUS 

SPHENOIDALIS 
SINISTER 


CELLULA 

ETHMOIOALIS 

ANTERIOR 


OS      IVASALE    " 


PROCESSUS 
FRONTALIS 


MEATUS 
NASI       INFERIOR 


CONCHA 
NASALIS 
INFERIOR 


CONCHA      NASALIS      MEDIA 


CONCHA      NASALIS      INFERIOR 


MEATUS      NASI       MEDIUS 


Fit;.    17. 

Sagittal    section    through    the    left    side   of   the    nose    internal    to    that    of 
Fi«s.   If!   and    1'!.     Inner   portion. 

a  needle  into  the  outer  wall  of  the  nose  just  above  the  posterior 
extremity  of  the  middle  tnrbinate. 

An  ethmoid  cell  lies  anterior  to  the  inl'iiiidibiilnm  running  par- 
allel to  it  and  resembling  it  in  shape  and  si/e.  As  has  been  already 
reported  by  the  writer,  a  probe  is  likely  to  enter  this  particular  type 
of  cell,  ti'i vin.u'  the  surgeon  the  impression  that  he  is  in  1  he  frontal  sinus. 
Sometimes  this  cell  or  another  anterior  ethmoid  cell  mav  project  far 

the  frontal  sinus,  constitntinii1  what   is  known  as  a  bulla  frontalis. 


THE    SrRlilCAL    ANATOMY    OF    THE    NOSH. 


Tlio  arrangement  of  the  ethmoid  labyrinth  is  shown  in  Figs.  17 
and  IS,  which  illustrate  the  1\vo  sides  of  a  sagittal  section  of  Ihe  nasal 
cavity  made  internal  to  the  one  in  the  specimen  illustrated  in  the  last 
two  figures.  On  one  side  the  posterior  portions  of  the  tnrbinate  are 
left  with  their  articulation  with  the  palate  hone,  and  on  oilier  their 
maxillary  attachments  are  preserved. 

Sphenoid  Sinus. — The  figures  show  two  very  large-  sphenoid 
sinuses,  the  right  extending  anteriorly  to  the  left  side  far  beyond  the 

SINUS      FRONTALIS 
INFUNDIBULUM        ETHMOIDALE 
CELLUL/t      ETHMOIDALES      POSTERIORES 


SINUS      SPHENOIDALIS      DEXTER 


SINUS 

SPHENOIDALIS 
SINISTER 


CELLULE 
ETHMOIDALES 
ANTERIORES 


CONCHA 
NASALIS 
SUPERIOR 


MEATUS      NASI       MEDIUS 


CONCHA 
NASALIS      INFERIOR 


MEATUS       NASI       INFERIOR 

Fig.   18. 


Sagittal   section   through   the   left   side   of   the    nose   internal    to   that   of 
Figs.   15   and   16.     External   portion. 

median  line,  and  the  left  posteriorly  almost  as  far.  The  sphenoid 
sinuses  occupy  a  greater  or  less  amount  of  the  body  of  the  sphenoid. 
The  two  sinuses  are  not  uniform  in  size,  shape  or  relation. 

A  sphenoid  sinus  may  extend  but  slightly  to  the  opposite  side, 
and  sometimes  it  may  grow  to  such  an  extent  on  the  opposite  side, 
that  the  other  sphenoid  is  reduced  to  an  exceedingly  small  size.  On 
the  other  hand  the  last  posterior  ethmoid  may  almost  entirely  replace 
it.  It  mav  extend  almost  as  far  back  as  the  Gasserian  ganglion,  and 


99 


OPERATIVE    STROERY    OF    THE    NOSE.    THROAT.    AND    EAR. 


to  the  basillar  process  of  the  occipital,  and  as  far  forward  as  the 
canalis  options.  Sphenoid  sinuses  of  various  sha])es  and  sizes  are  illus- 
trated in  Pigs.  of)  to  f>5. 

The  walls  of  the  sphenoid  sinus  vary  in  thickness  not  only  in 
different  individuals,  but  also  in  the  two  sinuses  of  the  same  head. 
This  statement  pertains  more  especially  to  the  superior  wall,  the 
effect  of  which  is  to  bring  the  pituitary  body  and  optic  nerves  much 


NERVUS   FRONTALIS 


CONCHA 
NASALIS 
SUPREMA 


APtRTURA 

SINUS 
SPHENOIDALIS 


NERVUS      TROCHLEARIS 


•       APERTURA 

SINUS 
SPHENOIDALIS 


NERVUS 
OCULOMOTORIUS 


NERVUS 
OPTICUS^--  _ 

NERVUS 
NASOCILIARIS   __  _ 

FOSSA 
SPHENOETHMOIDALIS         *  *  ",  y 


CONCHA 
NASALIS--  - 
SUPERIOR 


CONCHA 
NASALIS 
MEDIA 


CONCHA 
NASALIS 
INFERIOR 


CELLULA 
ETHMOIDALIS 
POSTERIOR 

ARTERIA 
OPHTHALMICA 


NERVUS 
OCULOMOTORIUS 


FOSSA 

-   -  SPHENOETHMOIDALIS 


SINUS 
.  ,    M  AXILLARIS 


V\K.  in. 

Coronal   section    through    nose   and    orbit    three    nun.   anterior   to   the   anterior 
wall    of   the   sphenoid    sinuses. 

closer  1o  otic  sinus  than  to  Ilic  oilier.  The  external  wall,  generally  the 
thickest,  lies  between  the  sinus  and  the  middle  cranial  fossa,  and  adjoins 
tin-  sinus  cavcrnosus  and  the  carotid  artery.  The  following  nerves  in 
addition  to  the  optic  are  found  in  relation  with  the  external  wall,  abdu- 
cens,  oculomotor,  trochlear,  ophthalmic  and  maxillary  (Fig.  8). 
The  posterior  wall  articulates  with  the  basillar  process  of  the 
occipital.  The  inner  wall  or  septum  sinuum  spheiioidalium  is  frequently 


THE    SURGICAL    AXATOMV    OF    THE    NOSH.  '2,} 

in  the  median  line,  but  from  what  lias  already  been  stated,  it  may  bo 
exceedingly  irregular  in  its  position.  (Fig.  57.) 

The  anterior  wall  is  in  relation  with  the  nasal  cavity  (rocossus 
sphenoethmoidalis)  and  the  posterior  ethmoidal  cell.  In  the  section 
(Fig.  19)  the  walls  of  the  nasal  cavities  have  been  cut  away  .'!  nun. 
anterior  to  the  sinus,  showing  the  relation  of  the  anterior  wall  to  the 
nasal  cavities  and  the  posterior  ethmoid  cells.  The  turbinates,  four 
in  number  on  each  side  are  cut  close  to  their  posterior  extremity.  The 
clioanai  are  visible  in  the  depths.  Their  position  with  respect  to  the 
sphenoid  sinus  and  to  the  posterior  portion  of  the  nasal  cavity  is  well 
shown.  It  will  be  observed  that  much  of  the  nasal  cavity  lies 
above  the  choamr,  quite  as  great  in  size  from  below  upward  as  the 
choanae  themselves.  This  figure  shows  how  the  sphenoid  may  be 
opened  with  or  without  the  destruction  of  the  posterior  ethmoid  cell. 
Compare  this  with  Fig.  8,  which  gives  a  view  of  the  sphenoid  anteriorly 
from  the  pharynx. 

The  orifice  of  the  sphenoid  sinus,  while  always  opening  into  the  nose 
above  the  superior  turbinate,  varies  considerably  in  its  position.  The 
following  table  shows  the  distance  between  the  inferior  margin  of  the 
opening,  and  the  lowest  level  of  the  floor,  and  the  highest  level  of  the 
roof  respectively,  in  fifteen  heads  measured  by  the  writer: 


DISTANCE   BETWEEN  THE   INFERIOR   MARGIN   OF   THE   NASAL 

OPENING    OF    THE    SPHENOID    SINUS    AND    THE 

FLOOR  AND  ROOF  OF  THE  SINUS. 

(In    Millimeters.) 


VI. 

17 

VII. 

7 

VIII. 

13 

IX. 

10 

X. 

13 

XI. 

12 

XII. 

4 

XIII. 

15 

XIV. 

16 

XV. 

2 

XVI. 

7 

XVII. 

12 

XVIII.                        6 

XIX. 

21 

XX. 

19 

13 
15 
14 
13 

9 
14 

4 

21 
22 

2 

14 

12 

4 


13 

20 

11 

4 

8 

11 
14 
17 


11 
14 
16 
13 
12 
15 
12 
19 
Id 
13 

i 

12 
14 

8 
10 


24  OPERATIVE  SUR<;ERY  OF  THE  XOSE,  THROAT,  AXD  EAR. 

These  figures  show  a  wide  variation,  and  yet  it  may  be  said  that 
the  orifice,  as  a  rule,  is  midway  between  the  roof  and  the  floor.  This  is 
true  for  twenty  out  of  thirty  sinuses. 

In  xix,  xx,  right,  the  orifice  is  in  the  upper  third  ;  in  VH  and  xvi, 
right,  and  ix,  xvi  and  xvm,  left,  it  is  in  the  lower  third;  in  the  other 
twenty-three  instances  it  is  in  the  middle  third. 

It  is  relatively  highest  in  head  xx,  right,  where  its  distance  from  the 
roof  is  one-tenth  of  that  between  the  roof  and  the  floor.  It  is  relatively 
lowest  in  ix,  left,  where  it  opens  in  the  lower  quarter  of  the  anterior 
wall. 

The  relation  of  the  cavernous  sinus  and  of  the  third  (oculomotor- 
ins),  fourth  (trochlearis),  fifth  (trigeminus),  sixth  (abducens)  and  the 
vidian  nerves  to  the  sphenoid  sinus  has  been  carefully  studied  by 
Sluder. 

He  found  that  the  body  of  the  sphenoid  is  covered  above  and 
laterally  by  the  dura  mater  with  the  cavernous  sinus  between  its  ex- 
ternal and  internal  surfaces,  occupying  a  position  for  the  most  part 
above  and  lateral  to  the  body.  Within  the  cavernous  sinus  are  found 
the  internal  carotid  artery,  and  the  third,  fourth  and  sixth  cranial 
nerves,  the  first  division  of  the  fifth  lying  in  the  lower  part  of  its  lateral 
wall.  The  sixth  and  third  division  of  the  fifth  are  the  only  ones  of 
these  nerves  that  are  not  at  times  in  close  association  with  this  cell, 
that  is,  separated  from  it  by  a  very  thin  layer  of  bone,  and  even  the 
third  division  of  the  fifth  is  sometimes  also  in  close  association  with 
it.  The  sixth  is  uniformly  placed  on  the  lateral  aspect  of  the  carotid 
while  within  the  cavernous  sinus  and  is  always  removed  from  this  bony 
wall. 

The  fact  which  determines  the  relations  of  these  nerve  trunks  to 
the  sphenoid  sinus  is  the  si/e  of  the  cavernous  sinus  rather  than  the 
si/c  of  the  sphenoid  sinus.  A  large  sphenoid  sinus  prolonged  hack- 
ward  and  outward  may  closely  approach  the  third  division  of  the  fifth 
in  the  foramen  ovale  or  even  the  (lasseriaii  ganglion.  (Set 

The  second   division   of  the   fifth   is  in   close  associat 
sphenoid    sinus    when    it    extends    laterally    to   the    fora  me 
The    first    division    of   the    fifth   comes    into   close   associat 
sphenoid  sinus  anteriorly  when  the  cavernous  sinus  is  sn 
direction.      'The   third   and    fourth    nerves    may    be   in    relal 
sphenoid  si  mis  when   it   is  prolonged  outward   into  the 
process   or   lesser   wing  of  t  he   s 
these    relations    in    the    sphenoid  a 
when  the  si  in  is  is  prolonged  into 
m ;  i  ir  n  a  ) . 

'I  In-   close   association    ol    the   sphenoid    sinus    with    the   second    di 


THE    SURGICAL    ANATOMY    OF    TIIK    XOSK 


25 


Fig.  20.     (Head  VI.) 


Fig.  21.      (Head  VII.) 


Fig.  22.      (Head   VIII. > 
Lateral   and   superior   reconstructions   of   the   accessory   sinuses    of   the  nose. 


26 


OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AXD    EAR. 


Fig.  23.      (Head  IX.) 


Fig.  24.      (Head  X.) 


Fig.   IT).      (Head   XI.) 
Lateral    and    superior    reconstructions    of    the    accessory    sinuses    of   the  nose 


THE    SURGICAL    ANATOMY    OF    THE    NOSE. 


Fig.  26.      (Head  XII.) 


Fig.  27.      (Head  XIII.) 


Fig.  28.     (Head  XIV.) 
Lateral   and   superior   reconstructions   of   the   accessory   sinuses    of   th*   nose. 


28 


OPERATIVE    SURCERY    OF    THE    XOSE,    THROAT,    AND    EAR. 


Fig.  29.     (Head  XV.) 


Fis.  30.      (Head  XVI.) 


XVJI.) 


<if    111. 


sinuses    of    tin1   nose 


TI1K    SrittllCAL    ANATOMY    OF    Till-:    NOSH. 


•29 


Fig.  :\'2.      (Head  XVIII.) 


Fig.  33.     (Head  XIX.) 


Fig.  34.      (Head   XX.) 
Lateral    and    superior    reconstructions   of   the    accessory    sinuses    of    th«     nosi 


30 


OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 


vision  of  the  fifth  in  the  foramen  rotnndmn  may  bo  established  as  early 
as  the  third  year  of  life,  and  with  the  vidian  nerve  in  its  canal  as  early 
as  the  sixth  year. 

Variations  of  the  Sinuses  in  Size  and  Shape. 

The  reconstruction  method  is  perhaps  the  best  for  illustrating  the 
variations  in  size  and  shape  of  the  sinuses.  Reconstructions  of  the 
sinuses  in  fifteen  heads  are  shown,  right,  left  and  superior.  In  Figs.  20 
to  34  inclusive,  the  central  illustration  is  the  superior  view,  the  right 
shows  the  left  set  of  sinuses,  and  the  left  the  right  set  (so  placed  in 
order  to  make  orientation  easy).  The  anterior  ethmoid  cells  are  repre- 
sented by  dotted  lines  and  the  posterior  by  broken  lines.  The  other 
sinuses  are  drawn  with  solid  lines,  as  they  are  obvious,  viz.,  in  the 
central  illustration  the  maxillary  are  the  most  external,  the  frontal  an- 
terior, and  the  sp,henoid  posterior;  in  the  lateral,  the  frontal  is 
superior,  the  sphenoid  posterior,  and  the  maxillary  inferior.  The 
ethmoid  cells  of  each  group  are  drawn  as  if  they  constituted  a  single 
sinus,  except  where  the  cells  were  too  far  distant  from  the  group. 
As  the  figures  are  reduced  to  one-half  the  natural  size,  it  is  easy  to 
estimate  the  extent  of  the  sinuses. 

In  the  central  figures  the  extent  of  the  sinuses  anteroposteriorly 
and  laterally  is  shown,  and  in  the  right  and  left  figures,  superoin- 
foriorly  and  anteroposteriorly.  The  corresponding  diameters  may  be 
thus  determined. 

Frontal  Sinus. —  While  there  is  a  great  diversity  of  shapes  to  be 
found  in  the  different  frontal  sinuses,  there  is  rather  more  uniformity 
of  shape  and  size  in  the  two  frontals  of  the  same  head.  The  dimen- 
sions in  millimeters  are  as  follows: 

DIAMETERS  OP'  THK  FRONTAL  SINUS. 

(In    Millimeters.) 

Head. 


VI. 

VII. 

VIII. 

IX. 

X. 

XI. 

XII. 

XIII. 

XIV. 

XV. 

XVI. 

XVII. 

XVIII. 

XIX. 

XX. 


Anteroposterior   Superoinferior 

Lateral 

!!. 

i.. 

u. 

i.. 

it. 

i,. 

15 

18 

24 

30 

20 

1:2 

'.','1 

33 

28 

26 

22 

26 

22 

16 

51 

28 

25 

11 

17 

21 

27 

36 

21 

37 

17 

17 

40 

37 

27 

22 

22 

16 

38 

.'58 

22 

15 

16 

22 

:u 

45 

10 

27 

17 

13 

25 

22 

21 

18 

26 

21 

45 

37 

42       37 

!) 

12 

14 

24 

7 

11 

12 

13 

35 

30 

26 

21 

2t; 

::o 

35 

4:5 

17 

23 

28 

21 

39 

41       2f> 

30 

12 

17 

30 

31 

28 

20 

26 

31 

46 

45 

'52 

24 

THE  SI;R<;ICAL  ANATOMY  OF  THE   NOSK. 


31 


up  as 


Tlic  variations  in  the  size  of  the  IVontals  may  be 
follows: 

Ran^o,  anteroposterior  9  to  .'5.'!,  superoinforior  14  to  .">!,  lateral  7 
to  42.  Usual,  leaving  out  five  highest  and  lowest,  anteroposterior  ID 
to  '26,  superoinferior  2(5  to  40,  lateral  17  to  30.  Average,  antero- 
posterior  21,  superoinferior  .'54,  lateral  2.'). 

The  largest  sinus  is  that  of  xiv  (Fiji1.  28)  ri.u'hl,  in  which  the 
diameters  are  2(5,  45,  42,  and  the  smallest  that  of  xv  (Fi,u\  29)  ri.u'ht, 
having  the  diameters  9,  14,  7. 

Maxillary  Sinus. — As  a  rule  the  maxillary  sinuses  in  a  .u'iven  head 
are  fairly  uniform  in  size  and  shape;  the  dimensions  of  the  maxillary 
sinuses  are  shown  in  the  following  table: 


DIAMETERS  OF   THE   MAXILLARY   STXTS   AND    DISTANCE    OF    THE 
FROM  THE  FLOOR  OF  THE  CAVITY. 

(In    Millimeters.) 


Distance  of 

Antero- 

Supero- 

Lateral 

opening 

from 

posterior. 

Inferioi 

floor  of 

cavity. 

HEAD. 

H.        I.. 

R. 

i.. 

it. 

i,. 

u. 

L. 

VI. 

39     40 

42 

32 

30 

25 

36 

28 

VII. 

40     42 

41 

47 

28 

29 

32 

39 

VIII. 

32     30 

28 

29 

19 

18 

24 

25 

IX. 

17     20 

17 

21 

8 

11 

15 

14 

X. 

39     37 

37 

40 

33 

30 

36 

38 

XI. 

40     40 

37 

39 

31 

29 

33 

34 

XII. 

34     29 

28 

28 

28 

25 

21 

•)•'} 

XIII. 

37     40 

45 

43 

29 

•!•> 

'  >  '' 

•I.) 

XIV. 

37     42 

38 

40 

25 

25 

2  3 

21 

XV. 

40     33 

38 

34 

24 

26 

3  3 

30 

XVI. 

25     26 

23 

26 

15 

17 

18 

24 

XVII. 

35     37 

31 

OQ 

32 

•>;> 

22 

25 

XVIII. 

35     26 

38 

26 

26 

19 

33 

21 

XIX. 

36     42 

45 

42 

27 

32 

40 

38 

XX. 

36     35 

39 

36 

25 

21 

36 

28 

The  variations  are  as  follows: 

Rauii'e,  anteroposterior  diameter  17  to  42,  superoinforior  1<  to  4,. 
lateral  8  to  33,  orifice  to  floor  14  to  40.  Usual,  leaving  off  highest  and 
lowest  five,  anteroposterior  29  to  40,  superoinferior  2S  to  42.  lateral 
19  to  30,  orifice  to  floor  21  to  36.  Average,  anteroposterior  :>s.  supero- 
inferior 38,  lateral  23.8,  orifice  to  floor  29.  The  largest  is  vn  ( 'Fi.u'.  21) 
left,  42,  47,  29,  the  smallest  is  ix  (Fi.ii1.  23)  riii'ht,  17,  17,  S.  It  will  be 
noted  that  leaving  out  a  few  of  the  extremes,  the  maxillary  sinuses  are 
more  uniform  than  anv  of  the  other  sinuses. 


0_  OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AXD    EAR. 

Ethmoid  Cells. — To  show  the  groat  complexity  of  the  ethmoid  cells 
and  the  variability  of  their  size  and  shape,  it  has  been  deemed  advis- 
able to  consider  the  diameters  of  the  ethmoid  labyrinth  and  of  the  an- 
terior and  posterior  groups  of  cells  respectively.  The  dimensions  are 
as  follows: 

DIAMETERS  OF  THE   ETHMOID  LABYRINTH. 

(In    MillimeU'rs.) 

Labyrinth  Anterior    Ethmoid     Posterior     Ethmoid 


HEAD. 

Antero- 
posterior. 

c  I 
K  '" 

"3 

t.' 

c 

6  '*" 

^  "33 

"•"  £ 
<  ~ 

c  | 
£  '" 

1 

Antero- 
posterior. 

Supero- 
inferior. 

~ 

VI. 

Right 

37 

23 

18 

23 

22   ' 

8 

28 

23 

28 

Left 

36 

20 

13 

22 

15 

9 

20 

17 

12 

VII. 

Right 

43 

34 

26 

22 

31 

8 

26 

34 

27 

Left 

47 

35 

20 

27 

12 

9 

30 

36 

20 

VIII. 

Right 

32 

26 

19 

32 

20 

16 

22 

17 

| 

11 

Left 

47 

39 

26 

24 

25 

11 

22 

32 

26 

IX. 

Right 

34 

39 

20 

21 

33  ! 

18 

23 

26 

12 

Left 

30 

36 

20 

20 

32 

19 

21 

28 

23 

X. 

Right 

35 

28 

14 

19 

25 

11 

20 

17 

13 

Left 

::r, 

28 

15 

21 

26 

15 

22 

19 

14 

XI. 

Right 

24 

33 

15 

10 

26 

11 

20 

18 

13 

Left 

''3 

29 

16 

14 

27 

11 

17 

15 

16 

XII. 

Right 

40 

20 

12 

40 

17 

12 

15 

6 

8 

Left 

34 

17 

12 

30 

17 

9 

13 

10 

11 

XIII. 

Right 

35 

31 

12 

14 

18 

9 

26 

!   23 

12 

Left 

35 

35 

18 

26 

35 

14 

25 

31 

18 

XIV. 

Right 

45 

59 

26 

26 

57 

26 

27 

30 

17 

Left 

46 

57 

28 

30 

50 

29 

32 

31 

12 

XV. 

Right 

33 

26 

9 

9 

7 

24 

24 

20 

9 

Left 

37 

26 

11 

17 

8 

26 

20 

i   22 

11 

XVI. 

Right 

32 

40 

15 

20 

35 

14 

99 

26 

12 

Left 

3  :> 

31 

99 

19 

28 

18 

28 

''  3 

16 

XVII. 

Right 

27 

19 

12 

9 

19 

7 

18 

17 

11 

Left 

99 

18 

in 

12 

16 

10 

16 

17 

10 

XVIII. 

Right 

54 

33 

16 

22 

18 

14 

14 

98 

_» 

15 

Left 

38 

25 

15 

30 

34 

12 

33 

23 

15 

XiX. 

Right 

•24 

2;> 

11 

16 

25 

13 

17 

18 

11 

Left 

25 

28 

11 

15 

28   ' 

11 

17 

1   20 

9 

XX. 

Right 

35 

4(1 

15 

28 

38 

11 

27 

35 

14 

Left 

32 

42 

13 

15 

29 

12 

25 

38 

13 

Those   figures   show   the   following: 

Ethmoid  Labyrinth.  K'smgv,  anteroposloi-ior  diameter  L'L'  to  7)4. 
superoini'erior  17  to  7>!>,  lateral  !'  to  L'S.  I  sual,  leaving  out  live  highest 
and  lowest,  antoropostorior  '27  to  4.'!,  superoinferioi1  -'.'>  to  .">(>,  lateral  1:2  to 
L'O.  Average,  antoropostorior  .'17),  suporoinforior  .'Jl.O,  lateral  Hi..'!. 

The  largest  is  that  of  xiv  (Fig.  l'S)  left,  4«l,  7)7,  L'S,  and  the  small- 
est, xvn  (Fig.  :$1  )  left,  ±J,  is,  10. 


TIIK   sri;<;ir.\i.   ANATOMY   OK   TIIK    NOSK. 

Anterior  Ethmoid.      Ran.uv,  anteroposterior  !»  to  40.  >uperoinfcri(.r 
7   to   ")7,   lateral   7   to  L'!).      Fsual,    leaving  out    live    highest    and    lowe>t. 
anteroposterior  1.4  to  L'7,  snperoinferior  17  to  .'14,  lateral  !'  to  1s.     Aver 
aii'e,    anteroposterior  L}1,  superoinferior  2~)A>,   lateral    14. 

The  largest   is  that  of  xiv   (  Fi.u'.  -S)    left,  .'!(),  .")(),  I'll,  and   the  small 
est  that  of  xvn   (  Fi.u'.  .'11  )   ri.n'ht,  !»,  1!»,  7. 

Posterior    Ethmoid. —  Ran.uv,    anteroposterior    l.'l    to    .'!.'!,    >upero 
inferior  (5  to  oS,  lateral  S  to  L'S.     Fsual,  leaving  out     five    highest    and 
lowest,  anteroposterior   17  to  L'(i.  su]>eroinferior   17  to  .'11,   lateral    11    to 
.IS.     Average,  anteroposterior  L'L'..'l,  snperoinferior  L'.'l.-'l,  lateral   14.7. 

The  largest  is  that  of  vn  (  Fii;'.  L'(i)  left,  :',(),  :i(i,  L'O,  and  the  smallest 
that  of  xn  (Fii>-.  L'(i)  ri^ht,  IT),  (i,  S. 

Sphenoid  Sinus. — -There   is  a  tremendous  variation   in   the  dimen- 
sions of  the  thirty  sphenoid  sinuses,  as  shown  in  the  following  table; 

DIAMETERS    OF    THE    SPHENOID    SINUSES 

(111      MillillH'UTS.) 


HEAD. 

Anteroposterior. 

Suporoinfcrior. 

Lat< 

>ral. 

>.;. 

i,. 

u. 

i.. 

K. 

[.. 

VI. 

35 

15 

30 

24 

31 

12 

VII. 

41' 

36 

99 

34 

34 

25 

VIII. 

25 

2(1 

27 

25 

16 

12 

IX. 

21 

14 

23 

17 

17 

13 

X. 

17 

14 

•>•> 

20 

17 

11 

XI. 

31 

L'7 

26 

26 

14 

!!• 

XII. 

9 

39 

8 

•26 

7 

24 

XIII. 

16 

33 

36 

36 

14 

'>  ~ 

XIV. 

24 

in 

38 

18 

:;.-> 

111 

XV. 

•> 

•);> 

4 

27 

2 

21 

XVI. 

20 

!l 

21 

10 

14 

S 

XVII. 

24 

14 

24 

19 

17 

17 

XVIII. 

9 

111 

in 

19 

li 

24 

XIX. 

32 

I'd 

28 

17 

•>~ 

12 

XX 

29 

30 

21 

2  i 

28 

.",4 

The  anteroposterior  diameter  varies   from  '2  mm.   in   > 
riu'ht,  to  4'J  imn.  in  vn   (  Fi.u'.  -1  )   riu'ht:  the  superoinferioi'  trom  4  in  N 
(Fi«»-.  I'D)  ri.i»'lit,  to  ;>S  in  xiv  (  Fi.ii'.  L'S )   ri.ii-lit:  lateral  from  L'  in  \ 
%J9)  riii'lit,  to  .'!.")  in  xm  (  b'i.u'.  L'7)  ri^ht. 


The  sphenoid  sinus  of  xv   (  M^.  'JiM    ri.u'ht,   is   by   far  t 
with  diameters  '2,  4  and  '2:  the  next  smallest  liein.u-  xn   (  Fi.u'.  '-Mil   riii'ht. 
with  diameters  1),  S  and  7.     That  of  vn   (  Fiir.  -1)   ri.u'lit,  is  the  largest 
with  diameters  4'2,  '2'2  and  :U:  while  that  of  vi    (  Fiu1    -'»>   riu'ht.  i-  next 
largest,  with  diameters  .'!."),  .'1(1  and  .">!. 


34  OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

The  average  diameters  of  the  thirty  sinuses  are  as  follows: 
Anteroposterior  21.5,  superoinferior  22.8,  lateral  18.4.  Excluding  five 
extremes,  smallest  and  largest,  the  range  of  the  remaining  twenty, 
which  may  be  considered  as  common,  is  as  follows:  Anteroposterior 
14  to  32,  superoinferior  17  to  27,  lateral  11  to  27. 


Fix.  :!.-).      (  Head   VII.) 
Piaster  casts  of  sphenoid   sinuses,   placed    in   situ. 

A  glance  at  the  reconstruction  of  the  sphenoid  sinuses  (Figs.  20 
to  34)  shows  the  great  variety  of  sixe  and  shape.  The  right  sphenoid 
xv  (Fig.  29)  is  hut  little  larger  than  its  opening  into  the  nasal  cavity, 
which  is  in  its  accustomed  position.  It  is  replaced  almost,  entirely  by 
the  left  sphenoid,  which  is  in  relation  with  the  optic  chiasm,  and  both 
nerves.  Both  sphenoids  of  vn  are  exceedingly  large  (Fig.  21)  and 
extend  far  behind  the  optic  chiasm,  sharing  this  feature  with  vi  (Fig. 


THK    SU1KJTCAL    ANATOMY    OK     IIIK     NOSK.  ,'!.") 

L'O)  right,  xn  (Fig-  -<>)  h'H,  xm   (Fig.    L'7)    left,    XYII    (Fig.    :!1  )    riulil, 
and  xix  (Fig.  IV,})  right. 

Thoro  is  likewise  .^i-cat  disparity  in  tin-  sixe  of  the  two  sphenoid 


Fig.  36.      (Head  XII.) 
Plaster  easts  of  sphenoid   sinuses,   placed   in   situ. 

sinuses  in  vi  (Fig.  '20),  XH  (Fig.  _()),  xiv  (Fig.  JS),    xv    (Fig.    :M>)    and 
xix  (Fig.  33). 

In  xvi  neither  sphenoid  is  in  relation  with  the  left  optic  nerve 
(Fig.  30).  A  large1  posterior  ethmoid  cell  replaces  the  left  sphenoid 
which  is  greatlv  reduced  in  si/.e. 


36 


OPERATIVE    SURGERY    OF    THE    NOSE,    THKOAT,    AND    EAR. 


Superficial  Area  and  Cubical  Capacity  of  the  Sinuses. 

In   order  to  determine  the  superficial   area   and  cubical   capacity 
of  the  sinuses,  it  is  necessary  to  make  casts  of  them  and  subject  these 


Fit;.    III.      (  Head    XIV.) 
faster   cast:-   of  sphenoid    sinuses,    placed    in    situ. 

to  some  standard  of  measurements.  liraniic  and  ( 'lasen  found  the 
cubical  capacity  hv  \'olnmetric  measnrejnents  of  metallic  casts  of  the 
sinuses.  The  writer  presented  ;i  method  at  the  International  Larynu'o- 


K    SI'KCICAL    ANATOMY 


..  i 


o^'ioal  Congress  in  Berlin  in  1!)11,  by  \vliicli  both  tin- 
capacity  and  flic  superficial  area  (for  the  first  lime)  were  determinable 
from  plaster  casts  made  of  the  sinuses  (except  the  ethmoidal)  in  serial 
sections,  and  then  properly  united  according  to  the  methods  used  by 


Fig.  :',8.      (  I  load  XXIII.) 
Plaster  casts  of  sphenoid   sinuses,   placed   in   situ. 


dentists.  A  number  of  illustrations  of  such  casts  of  the  sphenoids  are 
here  presented,  the  casts  beinir  placed  in  proper  position  in  the  lowest 
section.  A  far  better  understandinir  of  the  extent  and  variability  of 
the  sphenoid  sinuses  is  secured  by  this  method  than  by  any  other. 


38 


OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 


It  will  be  observed  that  the  sphenoid  sinuses  although  showing  little 
resemblance  to  one  another  in  the  different  heads,  are  fairly  uniform 
in  shape  and  size  in  VH  (Fig.  35),  xxm  (Fig.  38)  and  xxxv  (Fig.  40). 


Fig.   ::i).      (Head   XXVI.) 
Plaster  casts  of  sphenoid   sinuses,   placed   in   situ. 

These  are  all  large  except  xxin.  The  greatest  difference  is  to  be  seen  in 
xri  (Fig.  30)  in  which  the  right  sphenoid  is  reduced  to  a  cavity  2  by  2 
by  4  nun.  xiv  (Kig.  37)  and  xxvi  (Tig.  3!))  show  considerable  difference 
in  the  size  of  the  two  sphenoids. 


TIIH    SflililCAL    A  NATO  AH"    OK    'I  1 1  K     NOSK. 

The  results  of  the  measurements  mav  he  summari/ed  ;is  follow 


Superficial    Area    in 
Square    Centimeters. 


Cubical   Capacity   in 
Cubic   Centimeters. 


Sphenoid, 

Frontal, 

Maxillary, 


CJKKATKST 


28.2 

2.4 

11.8 

0.6 

:!2  :! 

r>  .  r, 

8.2 

0.!) 

52.3 

12.1 

28.4 

4.5 

Fig.   4U.      (Head  XXXV.) 
Plaster  casts  of  sphenoid  sinuses,   placed   in   situ. 


40 


OPERATIVE    SURiiERY    OF    THE    NOSE,    THROAT,    AND    EAR. 


Optic  Chiasm  and  Nerve. 

The  relation  of  these  structures  to  the  nose  and  accessory  sinuses 
is  of  importance  from  the  standpoint  of  both  pathology  and  surgery. 

SINUS      FRONTALIS      SINISTER  SINUS      FRONTALIS      DEXTE- 


CELLULA 
ETHMOIDALIS      POSTERIOR 


CELLULA 
ETHMOIDALIS       POSTERIOR 


SINUS      SPHENOIDALIS      SINISTE.     / 

^SINUS      SPHENOIDALIS       DEXTER 

ARTERIA      CAROTIS       INTERNA  ARTERIA       CAROTIS       INTERNA 

Fig.   41.      (Head   VI.) 
Preparation    showing    relation    of    optic    nerve    to    accessory    sinuses    of  the  nose. 

SINUS      FRONTALIS     SINISTER          SINUS      FRONTALIS      DEXTER 


CELLUL*  .- 
ETHMOIDALIS      POSTERIOR 


ARTERIA       CAROTIS       INTERNA 


"  -  SINUS 
SPHENOIDALIS       DEXTER 


ARTERIA       CAROTIS       INTERNA 


Kit;.    \'2.      I  Head    VII.) 
IMv-panit  ion    sliowing    relation    of    optic    nerve    to    accessory    sinuses    of    the   nose. 


TIIK    SCIiCICAL    A  NATO  AM'     OK    TDK     NOSK. 


41 


The  author  has  made  a  study  of  this  in  the  fifteen  heads  illustrated 
in  File's.  41  to  .">,")  inclusive.  These  are  the  same  heads  of  which  recon- 
structions were  made  as  shown  in  Fi.u's.  l'0  to  .'54  inclusive. 

SINUS      FRONTALIS      SINISTER  SINUS      FRONTALIS      DEXTER 


CELLULA 
ETHMOIDALIS      POSTERIOR     ,' 


SINUS  ,' 

SPHENOIDALIS     SINISTER 


CELLUL/e 
\     ETHMOIDALES      POSTERIORE! 


CAVUM      NASI 


\  SINUS 

Ns      SPHENOIDALIS      OEXTER 


ARTERIA      CAROTIS      INTERNA  ARTERIA      CAROTIS      INTERNA 

Fig  43.      (Head   VIII.) 
Preparation    showing-    relation    of   optic    nerve    to    accessory    sinuses    of    the  nose 


SINUS      FRONTALIS     SINISTER  SINUS      FRONTALIS      DEXTER 


CELLUt-A 

ETHMOIDALIS      ANTERIOR 


CELL 

ETHMOIDALIS 


SINL 
SPHENOIDALIS 


CELLULA 
ETHMOIDALIS      ANTERIOR 


NERVUS 
FACTORIUS 


ARTERIA    ,  ' 
CAROTIS      INTERNA 


NERVUS      OCULOMOTORIUS 


NERVUS     OCULOMOTORIUS 
SELLA"  TURCICA 


Fig.   44.      (  Head    IX.) 
Preparation    showing    relation    of    optic    nerve    to    accessory    sinuses    of   the   no; 


42 


OPERATIVE    SUKGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 


The  optic  cliiasm  in  these  heads  is  in  the  main  in  relation  with  one 
or  both  sphenoid  sinuses.  It  is  directly  upon  the  roof  in  heads  vi  (Fig. 
41)  both  sides;  vn  ( Fii>\  4:2);  xn  ( Fig.  47)  both  sides;  xm  (Fig-.  48)  left; 

SINUS      FRONTALIS      SINISTER  SINUS      FRONTALIS      DEXTER 

I  / 

INFUNDIBULUM       ETHMOIDALE  \ 


LAMINA      CRIBROSA 


CELLULA 

ETHMOIDALIS 

POSTERIOR 

SINUS          /' 
SPHENOIDALIS 
SINISTER 


ARTERIA      CAROTIS      INTERNA 


CELLULA 

ETHMOIDALIS 

POSTERIOR 

SINUS 
",     SPHENOIDALIS      DEXTER 

ARTERIA      CAROTIS      INTERNA 


Fig.  45.      (Head  X.) 
Preparation    showing   relation    of   optic    nerve   to    accessory    sinuses    of    the  nose. 

SINUS      FRONTALIS     SINISTER  SINUS      FRONTALIS      DEXTER 

\  / 

'  LAMINA      CRIBROSA 


SINUS 
SPHENOIDALIS       DEXTER 


NERVUS       OCULOMOTORIUS 


NERVUS      OCULOMOTORIUS 


Fig.   4«.      (Head   XI.) 
Preparation    showing    relation    of    optic    nerve    to    accessory    sinuses    of     the   nose 


THK    sritClCAL    ANATOMY    OF    TIIK     NOSK. 


xv      (Fig.    50)      Ici't;     xvii      (F 
xix  (Fig.  54)  both  sides. 

It  lies  considerably  above  the 
4!))  left;  xvi  (Fig.  51)  left. 

It  lies  posterior  to  the  sphenoid  sinus  in  vm   (  Fig.  4i! 


52)      right  ;    xvm      ( 
f  in  vm  (  Fiir.  4.'! 


i-.    5.'!)      left; 
eft;  xiv  (  Fiir. 
both  sides; 


ix  (Fig.  44)  both  sides;  x  (Fig.  45)  both  sides;  xi  (Fiji1.  4(1)  both  side>; 
xm  (Fig.  4S)  right;  xiv  (Fig.  4!))  both  sides;  xvi  (  Fig.  51)  both  side-; 
xvn  (Fig.  52)  left;  xx  (Fig.  55)  both  sides. 

It  is  thus  seen  that  in  more  than  half  of  the  instances  the  chiasm 
lies  posterior  to  the  sphenoid  cavity.  Special  attention  is  called  to 
vi,  vii,  xii,  xm,  xvn,  xix,  where  a  considerable  portion  of  the  sphenoid 
cavity  lies  beyond  the  anterior  margin  of  the  optic  ehiasni.  Xo  other 
cells  among  these  specimens  come  into  relation  with  the  optic  ehiasni. 

The  optic  nerve  may  be  described  as  passing  externally  1'roni  the 
ehiasni  along  the  roof  or  lateral  wall  of  the  sphenoid  sinus  in  slight 
relation,  usually  with  the  last  posterior  ethmoid  cell,  and  from  thence 
to  the  bulbils  opticus  through  the  periorbita. 

It  may  be  divided  into  a  sinus  portion  and  a  free  portion,  t'nder 
the  former  term,  I  include  that  part  of  the  nerve  in  immediate  relation 
with  the  accessory  cavities  of  the  nose  or  (arbitrarily)  within  .">  mm. 
of  the  sinus  wall. 

The  following  measurements  show  the  length  of  the  nerve  in  the 
different  beads: 

LKN<;TH  OF  OPTIC  NKHVK. 

(In    MilliiiK'trrs.) 


HEAD. 


VI. 

VII. 

VIII. 

IX. 

X. 

XI. 

XII. 

XIII. 

XIV. 

XV. 

XVI. 

XVII. 

XVIII. 

XIX. 

XX. 


Free  Portion. 

Sinus  Portion. 

R. 

i.. 

K. 

i.. 

i;. 

i.. 

44 

44 

21 

22 

2  3 

22 

54 

55 

22 

24 

32 

31 

40 

40 

21 

20 

19 

20 

45 

45 

18 

2(i 

27 

25 

37 

34 

18 

15 

19 

19 

54 

55 

26 

26 

28 

29 

45 

44 

22 

23 

23 

21 

39 

40 

15 

12 

24 

2S 

43 

4(1 

15 

14 

28 

26 

54 

47 

28 

•>- 

26 

20 

43 

44 

19 

18 

24 

26 

40 

40 

1!' 

0  '-' 

21 

17 

48 

45 

23 

20 

25 

25 

39 

37 

15 

14 

24 

90 

44 

44 

21 

''3 

23 

21 

The  following  variations  are  obtained: 
Optic  nerve:  range.  .'54  to  55;  usual,  leav 
five,  40  to  48;  average  44. 


g  off  highest  and  lowest 


44  OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AM)    EAR. 

Free  portions:  range,  12  to  .'>S;  usual,  leaving  off  highest  and  low- 
est five,  15  to  2.'>;  average  '20. 

Sinus  portion:  range,  17  to  .'>2;  usual,  leaving  of  highest  and  low- 
est five,  21  to  2S;  average  24. 

It  is  therefore  clear  that,  at  least  in  these  heads,  the  sinus  portion 
of  the  optic  nerve  is  a  trifle  greater  than  the  free  portion. 

There  does  not  appear  to  be  any  correspondence  between  the 
length  of  the  optic  nerve  and  the  extent  of  accessory  cavities. 

Where  the  sinus  is  very  large,  the  optic  nerve  has  its  origin  in 
the  chiasni  on  the  roof  of  the  sphenoid,  some  distance  anterior  to  the 
posterior  wall  of  the  sinus,  as  for  instance  in  vr  (Fig.  41)  right;  vn 
(Fiii1.  42)  both  sides:  xn  (Fig.  47)  left;  xm  (Fig.  4S)  both  sides; 
xx  (Fig.  55)  both  sides. 

Where  the  sinus  is  small,  the  optic  nerve  leaves  the  chiasni  ,u-en- 
erally  behind  the  sinus,  as  seen  in  vm  (Fig.  4.'>)  ;  ix  (Fig.  44)  both 
sides;  x  (Fig.  45)  both  sides;  xvi  (Fig.  51  )  both  sides.  Head  xvm  (Fig, 
5.'!)  is  somewhat  at  variance  with  this  rule,  but,  under  any  circum- 
stances, it  does  not  appear  possible  to  assign  the  variation  of  the  sinus 
as  an  explanation  for  the  varying  si/e  of  the  optic  nerve,  nor  for  the 
relation  which  the  sphenoid  opening  bears  to  the  optic  nerve. 

The  following  table  of  measurements  shows  this  difference. 

DISTAXCK    I5KTWKKX     LOWKH    STRKACK    OK    OPTIC    XKRVK.    AXD    XASAL 
OPKXI  X<;   OK   SIM  I  KXOII). 

(In     Millimeters.) 

Left. 

6 


14  1-1 

X  ~> 

11'  11 


Kan i:e,  ~2  above  to   14;  usual,  leaving  off  highest     and     lowest     live, 
'2  below  and    II;  average  (i. 

In  two  instances  xvm  (  l-'iu'.  .").'!)  both  sides,  and  xi\  (l^i.t;'.  54)  right, 


TIIK  sn:<;ir.\L  ANATOMY  OF  TIIK   NOSK. 


the  orifice  is  above  the  lower  surface  of  the  optic,  and  in  xin  (  Fix.  4*) 
left,  it  roaches  the  same  level.     In  nine  instances  out   of  the  thirtv,  tin- 


NERVUS      OLFACTORIUS 


POSTERIOR 


ARTERIA      CAROTIS      INTERNA 


S      INTERNA 


NERVUS       OCULOMOTORIUS 


NERVUS       OCULOMOTORIUS 

Fig.  47.      (Head   XII.) 
Preparation    showing    relation    of    optic    nerve    to    accessory    sinuses    of    the   nose 


CELLULA 
ETHMOIDALIS      ANTERIOR 


LAMINA      CRIBROS^ 


NERVUS       OCULOMOTORIUS 


CELLUL/E 
ETHMOIDALES       POSTERIORES 

SINUS      SPHENOIDALIS       DEXTER 

N  ARTERIA      CAROTIS       INTERNA 

& 

"fV 

NERVUS      TRIGEMINUS  NERVUS       OCULOMOTORIUS 

Fig.  48.      (Head   XIII.) 
Preparation    showing    relation    of   optic    nerve    TO    accessory    sinuses    of    the   nose 


46 


OPERATIVE    SURdERY    OF    THE    NOSE,    THROAT,,    AND    EAR. 


optic  nerve  lies  within  .'>  mm.  of  the  level  of  the  orifice  of  the  sinus. 
When  the  optic  nerve  lies  so  near  the  level    of    the    orifice    of    the 


BULLA    ETHMOIDALIS 


CELLUL/E      ETHMOIDALES        . 
ANTERIORES  \ 


DUCTUS     NASOLACRIMALIS 


CELLULA 
ETHMOIDALIS     ANTERIOR 


CELLULA       / 

ETHMOIDALIS      POSTERIOR  ,' 


SINUS  ,' 

SPHENOIDALIS     SINISTER 


"v.      CELLULA 
ETHMOIDALIS      POSTERIOR 


-„       SINUS 
SPHENOIDALIS       DEXTER 


ARTERIA     CAROTIS      INTERNA  ARTERIA      CAROTIS      INTERNA 

Fig.  4!».      (Head  XIV.) 
Preparation    showing    relation    of    optic    nerve    to    accessory    sinuses    of    the  nose. 


CAVUM       NASI 


CELLUL/E 
ETHMOIDALES       ANTERIORES 


CAVUM       NASI 

CELLUL/t 

LAMINA      CRIBROSA 


SPHENOIDALIS      SINISTER 


ARTERIA      CAROTIS      INTERNA 


Fig.   r.ii.      (  Hi  ad    XV. ) 
Preparation    showing    relation    of    optic    nerve    to    accessory    sinuses    of     the   nose. 


THK    Sl.'HCJCAL    ANATOMY    OF    TIIK    NOSK. 


sphenoid,  it  is  in  a  far  more  vulnerable  position  than  when  its  distance 
is  greater,  for  the  orifice  represents  the  possible  height  of  pus  in 
sphenoid  empvema  with  an  open  orifice. 


SINUS      FRONTALIS      SINISTER 


CELLULA 
ETHMOIDALIS      ANTERIOR 


SINUS      FRONTALIS      DEXTER 


CELLULA  / 

ETHMOIDALIS      POSTERIOR^ 


ARTERIA      CAROTIS       INTERNA 


ETHMOIDALIS 
POSTERIOR 


v  SINUS 

SPHENOIDALIS       DEXTER 


ARTERIA       CAROTIS       INTERNA 


Fig.  51.     (Head  XVI.) 
Preparation    showing   relation    of   optic    nerve   to    accessory    sinuses    of    the  nose. 


SINUS      FRONTALIS      SINISTER 


CELLUL/E 
ETHMOIDALES 
ANTERIORES 


SINUS      FRONTALIS      DEXTER 


CELLUL/E 
ETHMOIDALES 
ANTERIORES 


CELLUL/E 
ETHMOIDALES      POSTERIORES 


Fis 


ARTERIA      CAROTIS       INTERNA 
NERVUS      OCULOMOTORIUS 

Head  XVII.) 


Preparation    showing    relation    of    optic    nerve    ro    accessory    sinuses    of  the  nose 


48 


OPERATIVE    Sl'HCKHV    OF    THE    XOSE,    T1IHOAT.    AXI)    EAH. 


The  optic  nerve  as  a  rule  comes  into  relation  with  the  postero- 
external  aiii>'le  of  the  last  posterior  ethmoid  cell  at  its  roof,  and  from 
this  point  it  passes  in  an  external  direction  through  the  periorbita  to 


SINUS      FRONTALIS     SINISTER 

N 

LAMINA      CRIBROSA 


SINUS      FRONTALIS      DEXTER 


CELLULA 
ETHMOIDALIS      ANTERIOR 


CELLULA 
ETHMOIDALIS      POSTERIOR 


SINUS 
SPHENOIDALIS      SINISTER/' 


x  CELLULA 

ETHMOIDALIS      POSTERIOR 


\     CAVUM       NASI 


ARTERIA      CAROTIS      INTERNA  ARTERIA      CAROTIS      INTERNA 

Fig.  5::.      (Head  XVI 1 1.) 
Preparation    showing    relation    of    optic    nerve    to    accessory    sinuses    of    the   nose. 


SINUS      FRONTALIS      SINISTER 


SINUS      FRONTALIS      DEXTER 


LAMINA      CRIBRO3A 


NERVUS 
OCULOMOTORIUS 


Fig.    .VI.        (  ilr;i(l     XIX.  I 

'reparation    sliowiiig    relation    of    optic    nerve    to    accessory    sinuses    o 


THK    STUCK 'Ah    ANATOMY    OK    TIIK     NOSK.  4!* 

the  l)iilbus.  The  space  between  the  nerve  and  the  ethmoid  labyrinth 
increases  in  almost  direct  proportion  as  the  nerve  approaches  the 
bulbus,  and  its  junction  with  the  bulbus  is  generally  the  position  of 
greatest  distance  between  the  nerve  and  the  ethmoid  labyrinth. 

In  only  one  case,  xn  (Fig.  47)  does  the  anterior  ethmoidal  cell 
come  in  close  relation  with  the  optic  nerve,  replacing  a  posterior 
ethmoid  cell  which  lies  below  it.  The  relation  which  the  nerve  bears 
to  the  last  posterior  ethmoid,  when  that  cell  replaces  the  sphenoid, 


DUCTUi      NASOLACRIMALIS 


DUCTUS      NASOLACRIMALIS 


CELLULA 
ETHMOIDALIS      POSTERIOR 


SINUS      SPHENOIDALI; 


ARTERIA      CEREBRALIS      ANTERIOR 


CELLULA 

ETHMOIDALIS 
POSTERIOR 

LAMINA    CRIBROSA 
ARTERIA'    CEREBRALIS    ANTERIOR 


Fig.  55       (Head  XX.) 
Preparation    showing    relation    of    optic    nerve    to    accessory    sinuses    of    the   nose. 

is  very  characteristic,  for  in  the  two  instances  in  which  this  replace- 
ment is  present  in  the  heads  examined,  xvi  (  Fig.  ")1  )  and  xvm 
(Fig.  53),  the  nerve  is  found  to  run  along  the  external  wall  of  the 
cavity.  This  increases  the  ethmoid  portion  very  considerably,  chang- 
ing it  from  a  course  along  an  angle  to  one  along  a  wall  which  it  follows 
in  an  almost  surprising  manner.  This  probably  explains  the  cases  of 
optic  neuritis  which  complicate  an  ethmoiditis  without  an  accompany- 
ing spheuoiditis,  as  in  the  writer's  case  of  blindness  cured  by  ethmoid 
exenteratiou. 


50 


OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 


The  frontal  sinus  is  relatively  distant  from  the  optic  nerve,  the 
nearest  point  being,  as  a  rule,  at  the  inner  side  of  the  orbit,  and  here 
it  is  much  further  away  than  the  corresponding-  anterior  ethmoid  cells, 
which  ordinarily  lie  anterior  to  it  at  the  level  of  the  optic  nerve.  In 
some  instances,  however,  the  frontal  sinus  may  extend  for  a  consider- 
able distance  backward;  for  example  VH,  x,  xi,  xn,  xv,  xvn,  xvm,  xx. 
In  all  the  cases  the  sinus  is  much  closer  to  the  optic  nerve  than  where 
the  sinus  remains  anterior. 

In  all  the  specimens  the  periorbital  fat  makes  a  close  relation 
with  the  maxillary  sinus  impossible,  although,  in  some  instances,  the 
distance  is  less  than  1.0  mm. 

Nasolacrimal  Duct. 

The  increasing  disposition  to  treat  stenosis  of  the  nasolacrimal 
duct  by  operation  through  the  nose  justifies  a  study  of  its  topographic 


SINUS      FRONTALIS 


CELUULA        ETHMOIDALIS       ANTERIOR 


SINUS    SPHENOID«LIS 

'  NERVUS      OPTICUS 


SINUS 
ENOIDALIS 


Ki^ht  lateral  wall  of  the  nose  with  exposure  of  the  saccus  nasolacrimalis 
and    ductus   nasolacrimalis. 


TIIK    SriUilCAL    ANATOMY    OF    TIIK     XOSK. 


51 


relations  in  the  nose.  The  superior  and  inferior  canalicula-  lacrimales, 
whicli  start  at  tlie  pnneta  laeriinalis,  convey  the  tears  into  an  expanded 
pouch  called  the  saccus  laeriinalis  closed  above  and  bcin.i;'  continuous 
below  with  the  ductiis  nasolacriinalis  which  itself  opens  just  below  the 
maxillary  attachment  of  the  concha  inferior. 

The    saecus    laeriinalis    lies    in    the    fossa    lacrimalis    between    the 
crista  lacrimalis  anterior  and  the  crista  laeriinalis  posterior   (Fiu's.  !), 


ARTERIA 

>       INTEHNA 


SEPTUM 

SINUUM 

SPHEMOIDALIUM 


FOSSA      MEDIA 


NERVUS 
MAXILLARIS' 


DURA       MATER 


TORUS       TUBARIUS          CAVUM       PMARYNGIS 


OSTIUM       PHARYNGEUM 
TUB/E       AUDITIV/C 


Coronal  section  through  the  sphenoid  sinuses,  removal  of  septum  sinuuin 
sphenoidalium  and  exposure  of  the  hypophysis  l>y  enttin.u  away  the  bone  of 
the  posterior  wall  of  the  left  sphenoid  sinus. 

11).  It  extends  to  the  canal  (canalis  nasolacriinalis)  and  merges  into 
the  ductus  nasolacriinalis  which  runs  between  the  lateral  wall  of  the 
nose  and  the  maxillary  sinus. 

The  illustration  (  Fi,u'.  .")(>)  shows  the  course  of  the  sac  (the  ripper 
expanded  portion)  and  the  duct  alonir  the  external  wall  of  the  nose. 
In  the  specimen,  the  bone  of  the  external  wall  has  been  cut  away 


52  OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AXD    EAR. 

leaving  the  sac  and  the  duct  free  as  far  as  its  opening  below  the  in- 
ferior turbinate.  It  is  to  be  observed  that  they  lie  anterior  to  the 
middle  turbinate  and  anterior  and  inferior  to  the  first  ethmoid  cell 
which  is  here  exposed. 

Hypophysis  (Pituitary  Body). 

The  location  of  the  pituitary  body  or  hypophysis  behind  the  sphe- 
noid sinuses,  makes  it  a  factor  in  intranasal  surgery.  It  lies  in  the  fossa 
hypophyseos  of  the  sphenoid  bone  (Fig.  56).  It  consists  of  an  anterior 
grey  portion,  ectodermic  in  origin,  and  a  posterior  white  portion,  epider- 
mic in  origin,  connected  by  the  infundibulum  with  the  third  ventricle.  A 
reflection  of  the  dura,  diaphragma  selhe,  which  stretches  from  the  an- 
terior to  the  posterior  clinoid  processes  separates  the  hypophysis  from 
the  optic  chiasni  and  optic  tracts,  which  lie  just  above  it.  The 
infundibulum  penetrates  the  dura  behind  the  optic  chiasm  and  between 
the  right  and  left  optic  tracts.  Laterally  the  cavernous  sinus  surround- 
ing the  internal  carotid  artery  comes  into  relation  with  the  pituitary 
body  and  the  adjacent  structures.  Anteriorly  and  inferiorly  it  conies  into 
relation  with  the  sphenoidal  sinus,  as  shown  in  Figs.  V_*  and  56. 
Figure  57  is  an  illustration  of  a  preparation  made  by  cutting  away 
that  part  of  the  roof  of  the  sphenoid  sinus  forming  the  hypophyseal 
fossa  and  the  dnral  investment,  leaving  the  pituitary  body  free  in  the 
cavity.  The  septum  between  the  two  sinuses  has  also  been  removed. 
The  specimen  shows  how  the  hypophysis  may  be  safely  exposed  by  an 
(iidonasal  operation  through  the  sphenoid  sinuses. 

Vascular  Supply. 

Arteries. — The  arteries  of  the  external  nose  have  their  origin 
mainly  from  the  arteria  maxillaris  externa.  Branches  of  the  arteria 
ophthalmica  and  arteria  septi  communicate  with  the  network  from  the 
arteria  maxillaris  exlerna.  The  frontal  region  is  supplied  by  the  arteria 
ophthalmica,  the  arteria  frontalis  and  the  arteria  supraorbitalis. 

The  nasal  cavities  and  the  accessory  cavities  are  supplied  by  the 
branches  of  the  arteria  ophthalmica,  arteria  maxillaris  interim  and  the 
nrteria  maxillaris  externa. 

The  arteria  sphenopalatina,  terminal  branch  of  the  arteria  maxil- 
laris interim  passes  from  the  fossa  ptcrygopalat ina  through  the  for- 
amen sphenopalatimim  into  the  nasal  cavity,  giving  off  the  arteria' 
nasales  posteriores  and  the  arteria'  nasales  posteriores  septi  (nasopala- 
tilie). 

The    branches    of    these    vessels    supply    the    inferior,    middle    and 


THE    SlTK<iK'AL    ANATOMY    OK    'I  1 1  K    NoSK.  ,)'.} 

superior  turbinates,  the  mucosa  of  the  inferior  and  middle  meatus,  the 
sphenoid  sinus,  and  also  a  portion  of  the  septum. 

The  arteria  etlunoidalis  anterior  and  the  arteria  ethmoidalc 
posterior  leave  the  orbit  through  the  foramen  ethmoidalis  anterius 
and  the  foramen  ethmoidale  posterius  respectively,  enter  the  cranial 
cavity  passing  under  the  dura  and  perforate  into  the  nose  through  the 
lamina  cribrosa  supplying  the  ethmoid  cells,  and  the  upper  portion  of 
the  lateral  nasal  wall  and  septum. 

The  arteria  alveolaris  superior,  and  arteria  alveolaris  posterior 
and  the  arteria  infraorbitalis  su])])ly  the  inucosa  of  the  maxillary  sinus 
and  the  periosteum  of  the  maxilla. 

Veins. — The  venous  network  of  the  external  nose  is  connected  with 
that  of  the  vena  facialis  anterior  and  vena  ophthalmica,  the  following 
veins  collecting  the  supply,  vena  nasofrontalis  and  vena  angularis. 

The  veins  of  the  nasal  cavities  and  the  accessory  cavities  are  con- 
nected with  those  of  the  nasopharynx,  eye,  dura,  while  those  of  the 
mucosa  of  the  concha  are  connected  with  the  plexus  cavernosus  in  addi- 
tion. 

The  venous  supply  in  this  region  is  collected  by  the  vena  etlunoid- 
alis anterior  and  the  vena  ethmoidalis  posterior  which  enter  the  vena 
ophthalmica  superior  and  the  vena  ophthalmica  inferior. 

Innervation. 

The  nervus  olfactorius  sends  its  filaments  (fila  olfactoria)  about 
twenty  in  number,  through  the  lamina  cribrosa  and  they  supply  the 
inucosa  of  the  superior  and  middle  upper  part  of  the  turbinate  and  the 
septum  in  the  corresponding  position. 

The  first  and  second  branches  of  the  nervus  trigeminus  supply  the 
nasal  mucosa.  The  nervus  ethmoidalis  anterior  and  nervus  ethmoidalis 
posterior  originate  from  the  first,  and  the  nervus  sphenopalatinus  and 
nervus  infraorbital  from  the  second. 

The  nervus  ethmoidalis  posterior  which  is  accompanied  by  a  small 
branch  from  the  sphenopalatine  supplies  the  mucosa  of  the  sphenoid 
sinus  and  posterior  ethmoid  cells.  The  nervus  ethmoidalis  anterior  has 
three  branches,  the  ramus  septi  supplying  the  upper  portion  of  the 
inucosa  of  the  septum,  the  ramus  lateralis,  the  middle  turbinate  and 
anterior  portion  of  the  inferior  turbinate  and  posterolateral  wall  of 
the  nose  and  the  ramus  anterior  to  that  of  the  anterior  portion  of  the 
roof. 

The  nervus  infraorbitalis  gives  off  the  nervi  alveolares  superiores 
which  supply  the  mucosa  of  the  maxillary  sinus  and  anterior  part  of 
the  floor  of  the  nose.  The  ganglion  sphenopalatinum  gives  off  the  nervi 


54  OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AXD    EAR. 

nasales  which  supply  the  upper  and  posterior  portion  of  the  lateral  wall 
of  the  nose,  the  niucosa  of  the  superior  meatus/and  the  superior  and 
middle  turbinates  and  ethmoid  cells. 

The  nervi  nasopalatini  are  branches  of  the  ganglion  splienopala- 
tinuin  which  sup])ly  the  posterosuperior  portion  of  the  septum.  The 
rei'vus  nasopalatiims  is  the  largest  branch  of  the  sphenopalatine.  It 
passes  down  the  septum  to  the  canalis  incisivus  and  supplies  the  adja- 
cent portions  of  the  septum. 

The  nervus  ethmoidalis  anterior  supplies  the  niucosa  of  the  an- 
terior ethmoid  cells  and  frontal  sinus;  the  nervi  alveolares  supcriores 
the  maxillary  sinus;  the  nervus  ethmoidalis  posterior  and  the  nervi 
nasales  the  posterior  ethmoid  cells;  and  the  nervi  nasales  the  sphenoid 
sinus. 

Sympathetic  System. — Fibres  from  the  plexus  caroticus  pass 
through  the  ganglion  sphenopalat'mum  which  gives  off  fibres  which  are 
distributed  to  the  posterior  two-thirds  of  the  inferior  and  middle 
turbinate  and  nasal  septum. 


CHAPTER     II. 
SURGICAL  ANATOMY  OF  THE  PHARYNX,  LARYNX,  AND  NECK. 

Bv  (}KOI:<;K  B.  WOOD,  M.  I). 

THE  PHARYNX. 

The  pharynx,  which  is  a  funnel-shaped  tube,  is  divided  for  con- 
venience of  description  into  three  portions,  the.  nasopharynx,  oro- 
pharynx  and  the  laryngopharynx.  During  <|iiiet  inspiration  with  the 
month  closed  it  presents  anteriorly  in  order  from  above  downward 
the  posterior  mires  or  choamr,  the  soft  palate  with  its  anterior  pillars 
attached  to  the  tongue  and  its  posterior  pillars  to  the  lateral  wall  of 
the  pharynx,  the  epiglottis  (the  tip  of  which  is  almost  in  contact  with 
the  uvula),  the  laryngeal  opening,  the  posterior  surface  of  the  arytc- 
noid  bodies,  and  on  each  side  of  these,  the  pyriform  sinuses.  Each 
lateral  wall  presents  the  Eustachian  prominence  with  the  opening  of 
the  Eustachian  tube,  posterior  to  this  the  fossa  of  Rosenmiiller  and  be- 
low, the  lateral  folds  of  the  pharynx.  The  posterior  wall  is  a  smooth 
surface  showing  small  deposits  of  lyniphoid  tissue  and  is  continuous 
above  with  the  vault,  which  arches  forward  to  the  upper  part  of  the 
choaiue.  In  the  vault  is  situated  the  large  mass  of  lymphoid  tissue 
which  is  designated  the  pharyngeal  tonsil.  The  pharynx  is  greater 
in  its  lateral  than  in  its  anteroposterior  diameter,  the  greatest  breadth 
being  just  above  the  soft  palate. 

The  Nasopharynx. 

The  nasopharynx  extending  from  the  vault  to  the  lower  border 
of  the  soft  palate  is  an  open  cavity,  the  lateral,  superior  and  posterior 
walls  of  which  are  rigid.  The  choaiur  or  posterior  nares  are  two  oblong 
spaces  taking  the  place  of  practically  the  whole  of  the  anterior  wall. 
The  vault  or  fornix  of  the  pharynx  forms  the  roof  of  the  cavity  and  is 
occupied  in  part  by  the  pharyngeal  tonsil. 

The  Pharyngeal  Tonsil,  composed  of  lymphoid  tissue,  varies  ex- 
tremely in  size  and  shape.  It  may  consist  simply  of  a  few  small  eleva- 
tions scarcely  noticeable  to  the  naked  eye,  or  it  may  be  a  large  pendant 
mass  filling  the  greater  part  of  the  nasopharyngeal  cavity.  In  shape 

(55) 


56 


OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 


it  may  be  a  more  or  less  distinct  rounded  elevation,  placed  directly  in 
the  middle  of  the  vault  just  behind  the  upper  level  of  the  choanae  and 
the  upper  part  of  the  nasal  septum,  or  it  may  be  diffused,  spreading 
from  the  vault  out  into  the  fossa  of  Rosenmiiller,  downward  on  the 
posterior  pharyngeal  wall,  and  latterly  to  the  lateral  folds. 

On  each  side  of  the  pharyngeal  tonsil,  and  at  about  the  level  of 
the  posterior  end  of  the  inferior  turbinal  is  the  pharyngeal  orifice  of 


Fig.  r,8. 

Median  section  through  face  of  an  adult  man,  showing  the  normal 
relations  of  the  structures  during  quiet  nasal  respiration. 

1,  Frontal  sinus;  '2,  Anterior  palatal  pillar:  '.'>,  Posterior  palatal  pillar; 
4,  Sphenoid  sinus;  ~>,  Posterior  edge  of  nasal  septum;  6,  Fossa  of  Jtosen- 
miiller;  7,  Pharyngeal  tonsil;  8,  Ostium  of  Kustarhian  tube;  It,  Dotted  line 
showing  contour  of  the  tongue;  10,  Salpingopharyngeal  fold;  11,  Plica 
triangularis;  1L',  Palatal  tonsil;  I/!,  Lateral  pharyngeal  fold:  14,  Epi- 
glottis; ir>,  Ventricular  band;  Ki,  Vocal  cord. 

the  Eustachiau  tube.  The  opening  is  quite  large,  funnel-shaped,  with 
a  small  end  of  the  funnel  directed  towards  the  tympanum.  Above  and 
behind  the  opening  is  the  Kustacliian  prominence,  consisting  of  a 
rounded  ridge  formed  by  the  projection  of  the  Rustachian  cartilage. 


SURGICAL  AXA'I'OMY   OK  TI1K   IMIAKYXX,  LAKY.NX,  A  X  I )   XK.CK.  57 

The  anterior  margin  of  the  opening  is  much  less  prominent  than  the 
posterior  and  this  fact  helps  greatly  in  Ihc  introduction  of  the  Eu- 
stachian catheter.  Extending  downward  from  the  posterior  margin 
of  the  Eustachian  tube  is  a  fold  of  mucous  membrane,  the  salpingo- 
pharyngeal  fold,  which  is  gradually  lost  in  the  lateral  wall  of  the 
pharynx,  or  it  may  be  continuous  with  the  lateral  pharyngeal  fold.  A 
somewhat  similar  ridge,  but  much  less  marked,  is  the  salpingopalatine 
fold  which  runs  from  the  anterior  border  of  the  Eustachian  orifice 
downward  and  forward  to  the  palate.  Contraction  of  the  levator  palati 


9 

10 

11 

12 

13 


Median  section  through  the  face  of  an  infant  one  month  old,  showing 
the  relations  of  the  structures  during  quiet  nasal  respiration. 

1,  Superior  turbinate;  2,  Middle  turbinate;  3,  Inferior  turbinate;  4, 
Anterior  palatal  pillar;  5,  Body  of  sphenoid  bone;  6,  Eustachian  tube; 
7,  Pharyngeal  tonsil;  8,  Posterior  palatal  pillar;  9,  Dotted  line  showing 
contour  of  the  tongue;  10,  Plica  triangularis;  11.  Epiglottis;  12,  Ventricular 
band;  13,  Vocal  cord. 

muscle  produces  an  elevation  known  as  the  levator  cushion  which 
presses  to  a  greater  or  less  extent  against  the  lower  border  of  the 
Eustachian  orifice.  Behind  the  Eustachian  prominence  is  a  wedge- 
shaped  depression  called  the  fossa  of  Rosenmiiller,  or  the  lateral  recess 
of  the  pharynx.  This  depression  gradually  disappears  on  the  lateral 
wall  of  the  pharynx  at  about  the  level  of  the  soft  palate.  It  tends  to 
accentuate  the  Eustachian  prominence  and  the  salpingopharyngeal 
fold.  In  the  middle  of  the  vault  of  the  pharynx  is  a  sinus  running  up 
behind  the  pharyngeal  tonsil.  This  sinus  is  called  the  bursa  pharyngea, 
and  is  supposed  by  some  to  be  the  remnant  of  the  lower  portion  of  the 


58 


OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAE. 


pouch  of  Hatlike.    It  is,  however,  simply  an  occlusion  sinus  formed  by 
the  adhesion  of  folds  of  the  pliaryngeal  tonsil. 

The  vault  of  the  pharynx  receives  its  blood  supply  chiefly  from 
the  pliaryngeal  branch  of  the  vidian  artery.  The  branches  of  this 
artery  anastomose  with  the  ascending  pliaryngeal,  and  the  pharyngeal 
branch  of  the  pterygopalatine.  The  pterygopalatine  is  a  branch  of  the 
internal  maxillary,  while  the  ascending  pharyngeal  comes  directly  from 
the  external  carotid.  The  veins  follow  roughly  the  course  of  their  cor- 
responding arteries  and  open  into  the  pterygoid  plexus  which  is  situ- 
ated partly  on  the  inner  surface  of  the  internal  pterygoid  muscle,  and 


Fig.  60. 

Transverse  section  through  the  head  of  a  child  one  month  old,  just 
in  front  of  the  posterior  pharyngeal  wall.  The  neck  hai;  been  twisted  so 
that  the  larynx  is  thrown  somewhat  to  the  left.  Illustration  shows  the  rela- 
tion of  the  epiglottis  to  the  uvula. 


1,    Pharyngeal    tonsil;     2,    Nasal    septum; 
Trachea. 


:>,    Uvula:    4,    Epiglottis;    5, 


partly  around  tin-  external  pterygoid  muscle.  The  pterygoid  plexus 
empties  posteriorly  into  the  internal  maxillary  vein  and  anteriorly  into 
the  deep  facial  vein. 

The  lymphatic  drainage  of  the  vault  of  the  pharynx  is  through  a 
rather  close  mesh  of  lymph  vessels,  which  drain  either  into  the  rctro- 
pharyngeal  lymph  gland,  or  into  the  posterior  or  external  group  of  the 
deep  lateral  chain,  the  vessels  passing  posteriorly  to  the  large  vessels 
of  the  neck,  and  behind  the  rectus  capitis  anticus  muscle. 

The  nerve  supply  of  the  pharyngeal  vault  is  derived  from  the 
pharyngeal  branches  of  Meckel's  ganglion. 


St'KOK'AL  ANATOMY  OF  T  1 1  K   IM  1  Alt  Y  N  X  ,   LAKYNX,  AND    NKCK.  .)!< 

The  Oropharynx. 

The  division  between  the  nasopharynx  and  oropharynx  is  a  very 
movable  one  consisting'  of  the  free  edge  of  the  soft  palate.  The  upper 
surface  of  the  soft  palate  forms  an  anteroinferior  wall  to  the  naso- 
pharynx, while  the  inferior  surface  is  directed  towards  the  month,  hi 
the  infant  the  lower  border  of  the  soft  palate  reaches  almost  to  the 
epiglottis,  but  in  the  adult  there  is  more  space  between  the  epiglottis 
and  the  palate  which  is  tilled  in  by  the  dorsum  of  the  tongue.  The  an- 
terior wall  of  the  oropharynx  is,  therefore,  made  up  of  the  uvula,  phar- 
yngeal  portion  of  the  dorsum  of  the  tongue  and  the  epiglottis.  The 
lateral  diameter  is  about  twice  the  anteroposterior  diameter,  but  both 
of  these-  distances  are  constantly  changing,  according  to  the  action  of 
the  palatal  and  pharyngeal  muscles.  The  lateral  wall  of  the  oro- 
pharynx generally  presents  a  more  or  less  marked  perpendicular  ridge 
of  lymphoid  tissue,  sometimes  spoken  of  as  the  lateral  pharyngeal  fold. 

Palatal  or  Faucial  Tonsil. — The  palatal  tonsil,  more  generally 
spoken  of  as  the  faucial  but  less  correctly  so,  is  situated  in  a  fossa  be- 
tween the  anterior  and  posterior  palatal  or  faucial  pillars.  Both  in 
size  and  shape,  the  tonsil  varies  extraordinarily.  To  understand  this 
variation  we  must  study  the  development  of  the  organ.  Probably  the 
first  recognizable  sign  of  the  faucial  tonsil  is  to  be  found  in  the  embryo 
at  four  months.  At  five  months  there  is  a  distinct  vertical  groove 
about  '2  mm.  in  height,  at  the  bottom  of  which  a  small  mass  of  adenoid 
tissue  has  already  developed  and  in  this  mass  minute  slit-like  impres- 
sions can  be  found.  In  the  embryo  at  eight  months  the  form  of  the 
tonsil  is  fairly  constant.  At  this  time  the  tonsil  does  not  project  be- 
yond the  surface  and  is  covered  anteriorly  by  a  fold  called  the  plica 
triangularis  or  operculum.  This  fold  divides  a  little  above  its  middle 
into  two  distinct  branches,  one  running  anteriorly  to  the  tongue  form- 
ing a  fold  called  the  plica  pretonsillaris,  and  another  running  poste- 
riorly passing  round  the  base  of  the  tonsil  anlage  called  the  plica  infra- 
tonsillaris.  The  space  bounded  by  these  two  folds  above,  and  by  the 
tongue  below,  is  called  the  fossa  triangularis.  The  upper  part 
of  the  plica  triangularis  is  continued  above  the  tonsil  until  it 
meets  the  posterior  pillar  of  the  fauces  and  in  this  position  i> 
called  the  plica  supratonsillaris.  At  this  time  the  tonsillar  mass 
is  irregularly  divided  into  three  lobes  by  two  fissures,  running 
from  below  and  behind  upward  and  forward.  The  lower  and  middle 
are  merged  into  one  another  in  front  and  the  upper  and  middle  less  dis- 
tinctly so  behind.  At  the  junction  of  the  two  lower  the  plica  triangu- 
laris becomes  adherent  to  the  tonsillar  mass,  and  in  this  wav  a  recess 


60  OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,,    AND    EAR. 

is  formed  above  and  slightly  to  the  front  of  the  superior  convolution 
which  later  develops  into  the  supratonsillar  fossa.  In  the  majority  of 
children  at  birth  this  typical  condition  can  be  recognized  only  with 
difficulty,  as  the  tonsil  is  already  beginning  to  take  on  the  irregularity 
of  growth  which  is  one  of  its  characteristic  features.  After  birth  the 
development  of  the  tonsil  is  very  irregular,  and  its  final  shape  and  size 
depend  upon  the  position  and  amount  of  adenoid  tissue  present.  In 


4      — r 


Fig.  61. 
The  region  of  the  palatal  tonsil. 

1,  Supratonsillar  fossa;  2,  Uvula:  ?>,  Posterior  palatal  pillar:  4,  Kpi- 
glottis;  .">,  Plica  supratonsillaris;  6,  Dotted  line  showing  the  subsurface  extent 
of  the  tonsil;  7,  Anterior  palatal  pillar  made  prominent  by  traction  on 
ihe  tongue;  X.  Plica  triangularis ;  It,  Cut  surface  of  tongue,  traction  being 
made  df; \vn\vard. 

the  majority  of  cases  the  greatest  amount  of  development  takes  place 
in  tin;  lower  two  lobes.  These  by  their  growth  project  outward  and 
finally  hide  from  view  the  superior  lobe  which  can  be  found  only  by 
looking  deep  into  the  supratonsillar  fossa.  If  the  adenoid  tissue  de- 
velop:- in  the  supratonsillar  margin,  a  distinct  tonsillar  mass  will  be 
found  in  the  palate,  ;md  its  growth  downward  leaves  a  listuloiis  tract 
running  upward  from  the  hilnm  of  the  tonsil.  The  plica  triangularis 


SUmiU'AT,  ANATOMY  OF   T  1 1  K   IMIAIIYNX,   LAKYNX,  AND   NKCK.  (i  1 

may  remain  rudimentary  in  which  case  it  can  scarcely  he  seen,  or  it 
may  develop  so  as  to  cover  to  a  greater  or  less  extent  the  anterior 
portion  of  the  tonsillar  mass.  In  those  cases  in  which  the  development 
involves  chiefly  the  superior  lobe  the  snpratonsillar  fossa  becomes  al- 
most obliterated.  The  vagaries  of  the  growth  of  adenoid  tissue  in  the 
various  parts  of  the  tonsil  determine  the  shape  and  sixe  of  the  tonsillar 
mass. 

The  tonsil  is  separated  from  the  surrounding1  structures  by  a  dis 
tinct  fibrous  capsule.  This  capsule  surrounds  the  tonsil  on  all  sides 
except  the  mesial  free  surface.  At  the  front  it  runs  inward  beneath  the 
plica  triangularis  over  the  surface  of  the  tonsil  almost  to  the  line  where 
the  plica  merges  into  the  tonsillar  mass.  Behind  it  terminates  at  the 
free  edge  of  the  posterior  pillars,  above  it  reaches  to  the  supratonsillar 
margin,  but  below  it  does  not  come  quite  to  the  surface  epithelium,  as 
there  is  very  apt  to  be  a  thick  lymphoid  deposit  just  below  the  tonsil. 
The  capsule  sends  strong  fibrous  trabecuhe  into  the  substance  of  the 
tonsil  which  carry  the  blood  vessels,  lymphatics  and  nerves.  An  im- 
portant peculiarity  of  the  operculum  or  plica  triangularis  is  that  in  the 
fully  developed  tonsil  it  is  attached  firmly  to  the  tonsillar  mass  only 
close  to  its  very  edge,  and  can  be  readily  separated  from  the  capsule 
which  covers  the  front  of  the  tonsil. 

The  crypts  are  ingrowths  of  the  surface  epithelium,  their  lumina 
being  formed  by  the  desquamation  of  a  central  core.  These  crypts  vary 
both  in  number  and  in  sixe  but  they  generally  run  deep  into  the  ade- 
noid mass,  terminating  usually  close  to  the  capsule,  and  they  may  com- 
municate more  or  less  with  each  other.  They  are  as  a  rule  larger  and 
more  numerous  in  the  upper  part  of  the  tonsil.  In  the  usual  type  of 
tonsil  the  growth  of  the  two  lower  lobes  forms  a  dee])  pocket  close  to 
the  capsule,  with  its  opening  in  the  supratonsillar  fossa.  This  pocket 
is  not  in  the  true  sense  of  the  word  a  cry] it,  but  is  rather  an  inclusion 
recess  similar  to  that  which  forms  in  the  palate  from  overgrowth  of 
the  supratonsillar  margin. 

The  tonsil  is  surrounded  externally  by  the  pharyngeal  aponeu- 
rosis  which  is  rather  loosely  associated  with  the  capsule.  Ex- 
ternal to  this  is  the  superior  constrictor  muscle  of  the  pharynx.  Still 
further  externally  is  the  buccopharyngeal  fascia,  a  thin  and  in  places 
ill  defined  layer  which  surrounds  the  constrictors  of  the  pharynx  and 
the  outer  surface  of  the  buccinator  muscle.  Immediately  beyond  this 
rather  thin  covering,  the  tonsil  is  in  relation  with  a  space  filled  with 
loose  fatty  areolar  tissue.  The  outer  wall  of  this  space  is  formed  by 
the  internal  pterygoid  muscle;  its  posterior  wall  by  the  prevertebral 
muscles  and  the  internal  wall  by  the  pharynx.  This  triangular  space 


6'2 


OPERATIVE    Sl'RGERY    OF    THE    XOSE,    THROAT,    AXD    EAR. 


is  irregularly  <livido<l  into  two  smaller  spaces  by  the  stylopliaryngeus 
muscle,  and  external  to  this  by  the  styloglossus  muscle.  The  faucial 
tonsil  is  in  relation  with  the  anterior  of  these  two  divisions,  while  the 
internal  carotid  artery  is  placed  well  back  in  the  posterior  division. 
The  internal  carotid  is  never  closer  than  l.f)  cm.  from  the  wall  and 
the  pharynx  is  more  or  less  separated  from  it  by  the  interposition  of 
the  stylopharyngeus  muscle.  The  external  carotid  artery  lies  about  2 
cm.  from  the  lateral  wall  of  the  pharynx,  and  lias  interposed  between 
it  and  the  tonsil  a  portion  of  the  parotid  gland,  and  the  whole  of  the 


Dissection   of  the  region   of  the   palatal    tonsil    from   the  outside1. 

1,  Capsule  of  palatal  tonsil;  2,  Facial  artery;  '!,  I  lypei^lossal  nerve; 
4,  Superior  thyroid  artery:  f>,  Tonsillar  branch  of  facial  artery;  (!,  Occipital 
artery;  7,  Internal  care>tiel  artery;  8,  Lingual  artery;  !(,  External  carotid 
arte-ry;  10,  Spinal  acce>sse)ry  nerve;  11,  Common  care>tiel  artery;  1_.  De- 
scendens  hypo^leissi  nerve;  II!,  Pneuniogastric  nerve. 

musculature  of  the  styloid  process.  It  must  be  remembered,  however, 
that  the  outer  surface  of  an  enlarged  and  embedded  tonsil  is  not  in 
the  same  plane  as  the  pharynu'eal  wall,  and  it  thus  may  come  in  much 
closer  relation  to  the  large  blood  vessels  in  the  neck  than  the  above 
description  would  lead  one  to  suppose.  Furthermore,  the  facial  artery 
quite  frequently,  after  branching  from  the  external  carotid,  has  a  de- 
cided upward  bend  before  it  sweeps  outward  to  pass  around  the  rainus 
of  the  jaw.  When  this  upper  bending  is  marked,  the  loop  of  the  artery 
formed  comes  in  close  relation  to  the  inferior  portion  of  the  ton 


Sl'HOK'AL  ANATOMY   OF  T  1 1  K   1MIAKYNX,   I.AKYNX,  AND    NK(    K.  ().'{ 

sil,  making  it  possible  to  wound  this  artery  during  o|)eration>  on  the 
tonsils.  The  only  muscle  intervening  between  it  and  the  tonsil  is  the 
superior  constrictor.  The  two  carotid  arteries,  however,  are  sep- 
arated from  the  tonsil  by  the  stylopliaryngeus  and  the  styloglossus. 

Tbe  blood  supply  of  the  tonsil  comes  chiefly  through  the  tonsillar 
branch  of  the  facial  artery.  The  lower  part  of  the  tonsil,  however, 
may  be  supplied  from  a  branch  of  the  lingual,  sometimes  coming  from 
the  dorsalis  lingua*,  and  sometimes  from  the  main  lingual  trunk.  Oc- 
casionally tbe  palatine  branch  of  the  ascending  pharyngeal  supplies 
the  posterior  upper  part.  The  internal  maxillary  also  contributes  to 
the  blood  supply  of  the  tonsil  through  a  small  branch  coming  from  the 
posterior  or  descending  palatine.  The  division  from  the  facial  gener- 
ally  breaks  up  into  two  or  three  branches  which  penetrate  the  capsule 
and  which  again  break  up  into  numerous  branches  before  entering  the 
tonsil  with  the  trabecuhe.  Sometimes  almost  a  plexus  of  arteries  is 
formed  in  the  outer  layers  of  the  capsule  by  the  anastomoses  of  the 
supplying  blood  vessels. 

The  nerve  supply  of  the  tonsil  is  through  a  special  branch  of  the 
glossopharyngeal,  which,  uniting  with  branches  from  the  pharyngeal 
plexus  forms  what  might  be  called  a  small  tonsillar  plexus. 

Pillars  and  Lateral  and  Posterior  Walls. — The  anterior  palatal 
pillar  or  anterior  pillar  of  the  fauces  is  a  fold  caused  by  the  prom- 
inence of  the  palatoglossal  muscle,  while  tin-  posterior  pala- 
tal pillar,  or  posterior  pillar  of  the  fauces,  is  formed  by  the 
palatopharyngeal  muscle.  Behind  the  posterior  palatal  pillars  on 
each  side  of  the  pharynx  is  found  a  more  or  less  well-marked  mass  of 
lymphoid  tissue,  longitudinal  in  shape,  generally  spoken  of  as  the 
lateral  fold  of  the  pharynx.  This  longitudinal  elevation  appears  to  be 
a  continuance  downward  of  the  salpingopharyngeal  fold,  its  promi- 
nence, however,  is  due  not  to  a  prominent  muscle  but  to  the  lymphoid 
tissue,  which  according  to  Cortes  at  times  resembles  the  structures  of 
the  faucial  tonsil,  possessing  crypts  and  other  of  its  peculiar  histologic 
characteristics.  On  the  posterior  pharyngeal  wall  we  find  a  varying 
number  of  isolated  patches  of  lymphoid  tissue,  spoken  of  as  lymphoid 
follicles.  These  small  lymplioid  structures  are  more  numerous  in  the 
upper  part  of  the  throat,  and  seem  to  be  an  irregular  downward  ex- 
tension of  the  pharyngeal  tonsil. 

The  Laryngopharynx. 

The  laryngeal  portion  of  the  pharynx,  or  the  laryngopharynx,  ex- 
tends from  the  epiglottis  down  behind  the  larynx  to  the  level  of  the 
sixth  cervical  vertebra.  This  corresponds  about  to  the  lower  border 


64  OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 

of  the  cricoid  cartilage.  Below  the  arytenoid  cartilages  the  walls  of 
the  laryngopharynx  are  in  apposition  except  during  the  act  of  swal- 
lowing. In  front  of  the  epiglottis  and  on  the  base  of  the  tongue  is  an 
accumulation  of  lyniphoid  tissue  called  the  lingual  tonsil.  The  varia- 
tion in  size  and  shape  of  the  lingual  tonsil  is  very  marked.  Generally 
it  is  scarcely  more  than  a  rather  close  aggregation  of  separate  nodes, 
giving  simply  a  roughened  appearance  to  the  base  of  the  tongue. 
Sometimes,  however,  it  develops  in  two  lateral  masses  which  may  be  so 
large  as  to  be  more  or  less  pendulous. 

Below  the  lingual  tonsil  there  are  two  depressions,  the  bottom  of 
which  represents  the  junction  of  the  epiglottic  mucous  membrane  with 
that  of  the  tongue.  These  depressions  are  called  vallecula\  The  val- 
lecuhr  are  separated  by  a  distinct  fold  of  mucous  membrane,  the  median 
glossoepiglottic  fold,  or  as  it  is  sometimes  called  the  frenuin  of  the  epi- 
glottis. Each  is  bounded  externally  by  another  fold  of  mucous  mem- 
brane, the  lateral  glossoepiglottic  fold. 

The  pyriform  sinuses  are  deep  depressions  somewhat  boat-shaped, 
elongated  in  a  vertical  direction,  placed  on  each  side  of  the  upper  part 
of  the  larynx  between  the  ala  of  the  thyroid  cartilage  and  the  thyro- 
hyoid  membrane  on  the  outside,  and  the  arytenoepiglottic  fold  on  the 
inside.  They  are  bounded  anteriorly  by  the  lateral  glossoepiglottic 
folds,  and  posteriorly  pass  gradually  down  into  the  laryngopharynx. 

The  blood  supply  of  the  laryngopharynx  is  derived  solely  from  the 
external  carotid,  and  chiefly  through  the  ascending  pharyngeal 
branch.  Other  contributory  branches  are  the  ascending  palatine  branch 
of  the  facial,  and  the  tonsillar  branch  of  the  facial,  also  the  posterior 
palatine  and  pterygopalatine  brandies  of  the  internal  maxillary,  and 
sometimes  a  few  twigs  from  the  lingual.  The  smaller  veins  from  the 
pharynx  pass  into  a  pharyngeal  plexus  which  may  be  found  between 
the  biiccopharyngeal  aponeurosis  and  the  constrictors.  This  plexus 
anastomoses  with  the  pterygoid  plexus  above,  and  empties  below 
cither  into  the  internal  jugular  or  into  the  facial  vein. 

Lymphatics  of  the  Pharynx. 

The  lymphatics  of  the  pharynx  consist  of  a  network  beneath  the 
pharyngeal  epithelium  and  the  superficial  layer  of  the  mucous  ciitis. 
This  network  is  probably  most  marked  on  the  posterior  surface  of  the 
larynx  and  in  the  pyriform  sinuses;  it  is  also  very  rich  in  the  pharyn- 
U'eal  tonsil  but  very  scanty  near  the  esophageal  opening.  A  less  im- 
portant network  is  found  in  the  muscular  tissue. 

The  superior  collecting  trunks  generally  pass  first  to  the  rctro- 
pharyngeal  lymph  glands.  They  may,  however,  pass  by  these  glands 


St'UOICAI.  ANATOMY   OK  TIIK   IMIAKYNX,  I.AIiY.NX,  AND   NKCK.  ()•) 

and  terminate  in  the  deep  cervical  lymphatics,  and  according  1o  I'oirer, 
into  the  anterior  group,  hut  according  to  the  researches  of  the  author, 
both  anatomic  and  clinical,  they  terminate  in  the  posterior  group. 

The  middle  collecting  trunks  drain  the  mucous  membrane  of  the 
tonsillar  region.  These  vessels  perforate  the  muscular  coat  just  above 
the  great  cornu  of  the  hvoid  bone,  and  terminate  in  the  anterior  glands 
of  the  internal  jugular  group  near  the  posterior  belly  of  the  digastric 
muscle. 

Tlie  inferior  collecting  trunks  drain  the  lower  part  of  the  pharynx 
running  under  the  mucous  membrane,  and  tend  to  converge  in  the 
pyriform  sinuses.  They  here  unite  \vith  the  superior  lymphatics  of 
the  larynx  and  with  them  end  in  the  glands  of  the  internal  jugular 
group  just  below  the  digastric  muscle. 

The  lymph  vessels  of  the  soft  palate  are  very  numerous,  forming 
a  fine  network  which  is  more  or  less  continuous  with  that  of  the  neigh- 
boring  structures.  This  network  is  richest  in  the  uvula.  There  are 
separate  collecting  trunks  from  the  superior  and  inferior  surfaces  and 
from  the  faucial  pillars.  The  collecting  trunks  from  the  superior  sur- 
face are  more  or  less  united  with  the  collectors  from  the  nasal  fossa- 
which  may  be  divided  into  ascending  trunks  and  descending  trunks. 
The  former  pass  around  the  pharynx  and  terminate  in  the  retropharyn- 
geal  lymph  glands;  the  others  pass  down  through  the  posterior  pillars 
and  terminate  in  the  internal  jugular  glands  near  the  digastric  muscle. 
The  collecting  trunks  from  the  inferior  surface  run  downward  through 
the  anterior  pillars  and  joining  the  collectors  from  the  vault  of  the 
palate  terminate  in  the  internal  jugular  glands  near  the  digastric 
muscle.  The  collectors  of  the  anterior  pillar  unite  with  those  from  the 
inferior  surface,  and  the  collectors  from  the  posterior  pillar  with  the 
descending  trunks  of  the  superior  surface.  Occasionally  some  of  the 
lymphatic  vessels  from  the  posterior  pillars  terminate  in  the  glands 
of  the  internal  jugular  group  as  high  up  as  the  bifurcation  of  the 
carotids. 

Nerves  of  the  Pharynx. 

The  nerves  of  the  pharynx,  both  motor  and  sensory  come  mainly 
from  the  pharyngeal  plexus.  This  plexus  which  lies  just  beneath  the 
mucous  membrane  is  formed  by  branches  from  the  glossopharyngeal. 
from  the  pneumogastric  and  from  the  superior  cervical  ganglion  of 
the  sympathetic.  The  pharyngeal  branch  of  the  pneumogastric  is 
really  derived  from  the  accessory  portion  of  the  spinal  accessory.  Tin 
faucial  tonsil  receives  a  branch  directly  from  the  glossopharyngeal, 
while  the  surrounding  region  and  the  soft  palate  are  supplied  by  the 


6(J  OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

posterior  and  external  palatine  branches  of  Meckel's  ganglion.  The 
vault  of  the  pharynx  and  the  structures  around  the  orifice  of  the  Eu- 
stachian  tube  are  supplied  by  the  pharyngeal  branch  of  Meckel's 
ganglion.  The  mucous  membrane  on  the  external  posterior  wall  of 
the  larynx  is  supplied  by  the  superior  laryngeal  nerve. 

The  Structure  of  the  Pharyngeal  Wall. 

Surrounding1  the  mucous  membrane  of  the  pharynx  is  a  distinct 
layer  of  connective  tissue,  the  pharyngeal  aponeurosis.  This  fascia 
varies  in  thickness  being  usually  strongest  where  the  muscular  wall  of 
the  pharynx  is  weakest;  and  it  gradually  thins  out  as  the  lower  end 
of  the  pharynx  is  approached.  Above  it  blends  with  the  periosteum 
at  the  base  of  the  skull,  and  is  attached  to  the  Eustachian  tubes,  the 
margins  of  the  posterior  nares  and  to  other  portions  of  the  skull  from 
which  the  pharyngeal  constrictors  arise.  At  the  sinuses  of  Alorgagni, 
that  crescentic  space  between  the  base  of  the  skull  and  the  upper  bor- 
der of  the  superior  constrictor,  the  fascia  is  very  strongly  developed. 
Externally,  the  pharyngeal  aponeurosis  is  intimately  associated  with 
the  constrictors,  and  forms  the  capsule  of  the  faucial  tonsil. 

The  muscular  wall  of  the  pharynx  is  made  up  of  two  strata,  the 
internal  or  circular  layer  consisting  of  the  three  constrictors,  and  an 
external,  or  more  properly  longitudinal  layer,  consisting  of  fibres 
from  the  stylopharyngeus  and  from  the  palatopharyngeus  muscles. 
The  three  constrictor  muscles  appear  as  modified  cones,  the  middle 
overlapping  the  superior,  and  the  inferior  overlapping  the  middle. 

Tin-  Superior  Constrictor  Muscle  arises  from  1lie  lower  half  of  the 
posterior  border  of  the  internal  pterygoid  plate,  below  this  from  the 
pterygornandibular  ligament  and  from  the  internal  surface  of  the  man- 
dible just  back  of  the  last  molar  tooth.  It  is  also  attached  anteriorly  to 
the  mucous  membrane  of  the  floor  of  the  mouth.  The  upper  fibres  of  the 
muscle  curve  upward  and  are  inserted  into  the  plmryngeal  spine  of 
the  occipital  bone.  This  arching  of  the  upper  fibres  forms  a  crescentic 
interval  in  the  pharyngeal  wall  called  the  sinus  of  Morgagni.  Through 
this  opening  pass  the  Kustachian  tube  and  the  levator  and  tensor  palati 
muscles.  'Die  middle  and  inferior  fibres  of  the  superior  constrictor 
pas>  posteriorly,  radiating  upward  and  downward  to  be  inserted  into 
the  median  raphe  on  the  posterior  wall  of  the  pharynx.  The  lower 
fibre.-  are  overlapped  by  the  middle  constrictor, 

The  Middle  Constrictor  Muscle,  somewhat  smaller  than  the  snpe 
rior,  ari>es  from  the  stylohyoid  ligaments  and  from  both  the  small 
and  n'reat  corniia  of  the  hyoid  bone.  Its  fibres,  radiating  upward  and 
downward,  pa-s  posteriorly  to  be  inserted  into  the  median  raphe  of 


the  pharynx.  Tlio  lower  fibres  arc  overlapped  by  Hie  upper  fibres  of 
the  inferior.  The  interim!  laryn^en I  artery  and  nerve  pass  through 
tlie  interval  between  tlie  superior  and  middle  constrictors. 

The  Inferior  Constrictor  Muscle  a  rises  from  flic  obli(|ue  line  of  the 
thyroid  cartilage  and  from  the  sides  of  the  cricoid.  Ifs  fibres  radial- 
ing  mostly  upward,  pass  posteriorly  to  Ite  inserted  into  the  median 
pharyngeal  raphe.  The  lower  fibres  blend  with  the  musculature  of 
the  upper  end  of  the  esophagus.  At  the  lower  edge  of  the  muscle  the 
external  laryngeal  artery  and  nerve  come  into  relation  with  the  larynx. 

The  longitudinal  muscular  fibi'es  of  tlie  pharynx  are  made  np  of 
two  distinct  muscles,  the  palatopharyngeus  and  the  stylopharyngeus. 

The  Palatopharyngeus  Muscle  forms  the  posterior  faucial  pillar. 
It  is  composed  of  two  layers,  a  thin  posterior  superior  sheet  spread- 
ing through  the  substance  of  the  soft  palate,  and  a  thicker  antoroin- 
ferior  layer  which  arises  from  the  posterior  border  of  the  hard  palate. 
These  two  layers  partially  envelope  the  azygos  uvula1  and  levator 
palati  muscles.  They  unite  at  the  lower  edge  of  the  soft  palate  where 
they  receive  additional  fibres  from  the  Eustacliian  tube  and  passing 
downward,  spread  out  in  a  thin  sheet  in  the  wall  of  the  pharynx.  The 
posterior  fibres,  under  cover  of  the  middle  and  inferior  constrictors, 
are  inserted  into  the  aponeurosis  of  the  pharynx  and  some  fibi'es 
decussate  with  those  of  its  fellow  of  the  opposite  side.  The  anterior 
fibres  are  inserted  into  the  posterior  border  of  the  thyroid  cartilage 
and  anteriorly  merge  into  the  stylopharyngeus. 

The  Stylopharyngeus  Muscle  arises  from  the  base  of  the  styloid 
process.  Passing  downward  and  forward  between  the  two  carotid  ar- 
teries it  penetrates  the  pharyngeal  wall  between  the  superior  and  middle 
constrictors.  It  is  inserted  by  a  broad  base  into  the  superior  and  poste- 
rior border  of  the  thyroid  cartilage,  its  fibres  being  here  continuous 
with  the  palatopharyngeus.  It  is  also  inserted  into  the  pharyngeal 
aponeurosis. 

The  soft  palate  and  uvula  may  be  considered  as  the  anterior  wall 
of  the  pharynx.  They  are  made  up  of  a  muscular  fold  covered  by  mu- 
cous membrane. 

The  muscles  which  constitute  the  soft  palate  consist  of  five  pairs 
—the  palatopharyngeus  (already  described),  the  palatoglossus,  tlie 
axygos  uvula*,  the  levator  palati  and  the  tensor  palati. 

The  Palatoglossus  Muscle  is  placed  directly  beneath  the  mucous 
membrane  of  the  tongue,  the  anterior  palatal  pillar,  and  the  anterior 
surface  of  the  palate.  It  is  a  thin  sheet  of  muscular  fibres  which  arise 
from  the  under  surface  of  the  soft  palate,  some  of  its  fibres  blending 
with  those  of  its  fellow  of  the  opposite,  and  passes  downward  to.  form 


68 


OPERATIVE    SUROERY    OF    THE    NOSE,    THROAT,    AND    EAR. 


the  anterior  pillar  of  the  fauces.  It  is  inserted  into  the  sides  of  the 
tongue,  and  blends  with  the  styloi^lossus  and  deep  transverse  fibres  of 
the  tongue. 

The  Azygos  Uvulae  Muscle  is  found  between  the  layers  of  the 
palatopharyngeus  and  arises  from  the  posterior  nasal  spine  and  the 
aponenrosis  of  the  soft  palate.  The  two  narrow  bundles  unite  as  they 
proceed  downward  to  the  tip  of  the  uvula. 


11 


-14 


Dissection  showing  the  relation  of  the  tensor  palati  and  the  levator 
palati  muscles.  The  levator  is  cut  permitting  the  soft  palate  to  be  drawn 
forward. 

1,  Kustachian  cartilaK''!  -,  Tensor  palati  muscle;  ',",,  Levator  palati 
muscle;  4,  Ilamular  process;  f>.  Internal  pteryn'oid  muscle;  6,  Middle 
constrictor  of  pharynx;  7,  Posterior  palatal  pillar;  8,  Sphenoid  sinus;  !>, 
Middle  turbinate;  10,  Inferior  tnrbinate;  11,  Tendon  of  tensor  palati  mus- 
cle; l~2.  Insertion  of  levator  palati  muscle;  II!,  Cut  edi;e  of  velum  palati;  14. 
Palatal  tonsil:  1".,  Section  of  tongue. 

The  Levator  Palati  Muscle  arises  from  the  inferior  surface  of  the 
apex  of  the  petrous  bone  dose  to  the  carotid  canal.  Its  fibres  forming 
a  rounded  belly,  run  parallel  to  and  in  close  approximation  with  the 
under  surface  of  the  Kustachiaii  tube,  to  which,  however,  it  is  not  at- 
tached. It  is  inserted  in  a  radiating  manner  into  the  soft  palate  below 


the  ostium  of  the  tube.  The  action  of  this  muscle  on  the  Kiistachian 
tube  is  not  exactly  understood.  The  contraction  of  the  muscle  by  in- 
creasing its  circumference  tends  to  raise  the  floor  of  the  tube,  which, 
by  decreasing  the  perpendicular  width  of  the  lumen  of  the  tube,  in- 
creases the  horizontal,  and  this  probably  increases  the  patulency  of 
the  tube. 

The  Tensor  Palati  Muscle  is  the  real  abductor  or  dilator  tuba-.  It 
arises  in  part  from  the  scaphoid  fossa  of  the  internal  pterygoid  plate 
and  the  alar  spine  of  the  sphenoid  bone,  and  in  part  from  the  outer  sur- 
face1, or  the  hook-like  border  of  the  cartilaginous  wall,  and  the  membran- 
ous part  of  the  Eustachian  cartilage.  Running  downward  so  as  to  form 
an  acute1  angle'  with  the1  cartilaginous  portion  of  the  tube,  the  muscle 
ele'sevnels  between  the  internal  pterygoid  muscle  and  the  internal  ptery- 
goid plate1.  It  te'rminate's  by  a  rounded  tendon  which  passes  around 
the1  hook  of  the1  hamular  process  and  is  inserted  beneath  the  levator 
palati  into  the  pe>sterie>r  be>rder  of  the  hard  palate,  as  well  as  the  apo- 
ne'urosis  of  the1  soft  palate.  The1  action  of  this  muscle,  by  pulling  on 
the  cartilaginous  hoe>k  of  the*  Eustachian  tube,  tends  to  slightly  unfold 
it,  which  action  increase's  the'  lume'ii  of  the'  tube. 

The1  nerve  supply  to  the-  musculature  of  the  pharynx  is  chie'fly 
through  the  spinal  ace-essory  by  way  of  the'  pharyngeal  plexus.  This 
plexus  supplier  the  constrictors  of  the'  pharynx,  the1  palatoglossus,  the 
palatopharyngeus,  the1  azygos  uvula1,  and  the  levator  palati.  The  ten- 
sor palati  is  supplied  from  the  otic  ganglion,  the  stylopharyngeus  by 
the1  glossopharyngeal  neM've,  and  the1  infVrior  constrictors  receive 
branches  frenn  the1  vagus  through  the  external  and  recurrent  laryugeal 
nerves. 

THE   LARYNX. 

The1  larynx  should  be  looked  upon  as  the  upper  part  of  the  trachea, 
especially  modified  for  the1  preulue'tieHi  of  the1  ve>ice  sound.  Its 
construction  is  such  as  to  permit  the  instant  approximation  and  adjust- 
me'iit  of  two  elastic  bands,  the1  voe-al  cords.  These  may  be  thrown  into 
the  required  vibrations  by  a  column  of  air  forced  up  through  the  tra- 
che'a.  To  accomplish  this  purpose  numerous  joints,  ligaments  and 
muscles  are  necessary.  By  reason  of  the  be'auty  and  perfection  of  the 
arrange'ine'iit  of  these  various  strue'tures  the  larynx  is  one  of  the  most 
interesting  organs  of  the1  body  to  the  anatomist.  It  is  situated  in  the1 
me'dian  line  of  the1  nevk  just  in  front  of  the1  esophagus,  and  is  very 
loosely  attached  to  the  surrounding  strue'tures.  ( )u  each  side  poste- 
riorly are  the'  large  vessels  of  the  ue'ck,  and  above1  are  the  hyoid  bone 
and  tongue. 


70  OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AXD    EAR. 

The  interior  of  the  larynx  opens  into  the  lower  portion  of  the 
pharynx  just  back  of  and  below  the  base  of  the  tongue.  The  aclitus 
laryngis  is  obliquely  placed  facing  upward  and  backward.  It  is  bor- 
dered above  by  the  epiglottis,  on  each  side  by  the  arytenoepiglottic 
folds,  and  posteriorly  by  the  mucous  membrane  covering,  the  carti- 
lages of  AVrisberg  (cuneiform  cartilages)  and  of  Santorini  (cornicula 
laryngis).  These  cartilages  surmount  the  arytenoid  cartilages  and 
follow  their  movements. 

The  interior  of  the  larynx  is  divided  into  three  parts  by  the  false 
and  true  vocal  cords  (ventricular  and  vocal  bands). 

Superior  Division. 

The  superior  division  of  the  laryngeal  cavity  is  compressed  later- 
ally where  the  ventricular  bands  or  false  cords  separate  it  from  the 
middle  division.  The  anterior  wall  is  formed  in  greater  part  by  the  pos- 
terior surface  of  the  epiglottis.  The  upper  part  of  the  posterior  sur- 
face of  the  epiglottis  is  concave  except  the  tip  which  is  turned  slightly 
forward.  Below,  the  epiglottis  shows  a  distinct  swelling,  the  cushion 
of  the  epiglottis.  This  swelling  corresponds  in  position  to  the  thyro- 
epiglottic  ligament.  The  lateral  walls  are  smooth  except  for  two  slight 
vertical  elevations,  the  anterior  being  due  to  the  cuneiform  cartilage 
and  the  posterior  to  the  anterior  margin  of  the  arytenoid  cartilage  and 
the  cartilage  of  Santorini.  The  shallow  grove  between  these  eleva- 
tions is  called  the  philtrum  ventriculi  of  Merkel.  The  anterior  of 
these  elevations  runs  to  the  posterior  end  of  the  false  vocal  cords  while 
the  posterior  passes  downward  to  the  true  cords.  The  narrow  pos- 
terior wall  is  formed  by  the  interarytenoid  fold  and  varies  in  breadth 
according  to  the  degree  of  approximation  of  the  arytenoid  cartilages. 

The  Ventricular  Bands,  or  false  cords,  form  a  partial  floor  of  the 
superior  division  of  the  larynx.  In  front  they  arise  from  the  angle 
between  the  two  wings  of  the  thyroid  cartilage,  and  they  reach  back- 
ward only  to  the  swelling  on  the  lateral  wall  causer!  by  the  cuneiform 
cartilages.  They  are  never  in  apposition  and  they  never  obscure  the 
maririn  of  the  true  vocal  cords  from  view.  The  chief  support  of  this 
fold  of  mucous  membrane  is  the  thin  superior  thyroarytenoid  ligament 
and  a  few  muscle  fibres.  The  distance  in  the  adult  male  larynx  from 
the  ventricular  band  to  the  summit  (if  the  arytenoid  cartilages  is  about 
one  half  inch  and  to  the  tip  of  the  epiglottis  one  and  a  half  inches. 

Middle  Division. 

The   middle   division    of  the    larynx    is    limited    above   by    the 
cords  and    below   bv   the  true.      (  )n   each   side  and   covered    bv   the 


SURGICAL  ANATOMY  OF  TIIK   PHARYNX,  LARYNX,  AND    NK<    K.  <   1 

tricular  bands  is  the  laryngeal  sinus  or  ventricle  of  Morgagni.  !t> 
cavity  is  somewhat  larger  than  its  opening  and  it  roadies  from  the  an- 
terior angle  of  the  ahr  of  the  thyroid  cartilage  hack  to  the  anterior 
border  of  the  arytenoid  cartilage.  This  ventricle  of  Morgagni  is  ex- 
tremely variable  both  in  shape  and  size.  It  may  consist  simply  of  a 
single  broad  pocket  extending  upward  between  the  ventricular  band 
and  the  ala  of  the  thyroid  cartilage  or  it  may  be  a  branched  structure 
with  a  varying  number  of  terminal  crypts.  Occasionally  there  exists 
a  short  branch  directed  downward  from  the  main  pocket.  The  walls 
of  the  sinus  contain  quite  a  largo  deposit  of  lymphoid  tissue  and  fre- 
quently if  not  always  definite  germinating  follicles  are  present  so  that 
the  whole  structure  is  very  similar  to  a  large  tonsillar  crypt.  The 
upward  extension  of  the  sinus  is  quite  commonly  spoken  of  as  the 
laryngeal  saccule  and  it  does  not  usually  extend  upward  beyond  the 
border  of  the  thyroid  cartilage,  though  in  rare  instances  it  may  reach 
to  the  posterior  part  of  the  hyoid  bone. 

The  True  Vocal  Cords  are  shorter  but  more  prominent  than  the 
false  and  extend  from  the  angle  formed  by  the  ala1  of  the  thyroid  to 
the  vocal  processes  of  the  arytenoid  cartilages.  In  cross  section  the 
cord  is  prismatic  with  the  free  edge  pointing  upward,  as  well  as  to- 
ward the  median  line.  In  front,  the  cords  meet  and  form  the  anterior 
commissure.  Posteriorly,  they  end  at  the  vocal  processes  of  the  ary- 
tenoid cartilages,  but  their  surface  lines  an4  continued  over  the  median 
side  of  the  arytenoid  cartilages,  joining  posteriorly  to  form  the  poste- 
rior commissure.  The  true  cords  with  the  opening  between  them  con- 
stitute the  true  glottis,  or  rima  glottidis  which  is  generally  designated 
the  glottis. 

Inferior  Division. 

The  inferior  division  of  the  larynx  is  somewhat  flattened  laterally 
above  and  below  where  its  walls  slope  outward  and  downward  from 
the  vocal  cords.  Its  walls  are  in  greater  part  made  up  by  the  inner 
surface  of  the  crieothyroid  ligament. 

Cartilages  of  the  Larynx. 

The  Cricoid  Cartilage  is  the  lowest  and  is  placed  directly  on  top 
of  the  trachea.  It  is  shaped  somewhat  like  a  signet  ring,  with  the  signet 
part  or  posterior  lamina  projecting  from  the  upper  side  and  the  upper 
edge  sloping  rather  gradually  downward  and  forward  to  form  the  ante- 
rior circle.  The  ring  is  circular  below  corresponding  to  the  shape  of  the 
trachea,  but  above  it  is  somewhat  laterally  compressed.  On  top  of  the 
posterior  lamina  are  two  oval  convex  facets  which  look  somewhat  out- 


72  OPERATIVE    SUROERY    OF    THE    XOSE,    THROAT,    AXD    EAR. 

ward  as  well  as  upward.  Tlioy  are  tlio  articulating  surfaces  for  the  ary- 
tenoid cartilages  and  are  separated  by  a  faiut  median  notch.  On  the 
posterior  surface  are  two  depressed  areas  for  the  attachment  of  the 
posterior  crieoarytenoid  muscles.  On  the  posterior  part  of  the  lateral 
surface  of  the  cricoid,  a  vertical  ridge  runs  downward  from  the  aryte 
noid  articulation.  On  this  ridge,  just  above  the  lower  border  of  the 
cartilage  is  a  circular  facet  for  articulation  with  the  inferior  horn  of 
the  thyroid  cartilage.  The  inner  surface  of  the  cricoid  is  smooth. 

The  Arytenoid  Cartilages,  two  in  number,  are  perched  on  the  ante- 
rior part  of  the  summit  of  the  posterior  lamina  of  the  cricoid.  They 
are  irregularly  pyramidal  in  shape  and  have  three  surfaces  and  a  base. 
When  the  cartilages  are  in  position  for  phonation  one  surface  faces 
directly  toward  the  median  line,  another  posteriorly  and  the  third  out- 
ward and  forward.  The  posterior  and  anteroexternal  surfaces  are 
somewhat  concave,  slightly  triangular,  narrowed  vertically  and  fairly 
even.  A  small  sesamoid  cartilage  is  frequently  found  invested  by  the 
perichondrium  on  the  external  border  of  the  arytenoid  cartilage.  The, 
apex  is  directed  upward,  but  is  curved  slightly  inward  and  backward. 
There  are  two  important  processes,  one  the  external  inferior  angle 
called  the  processus  muscularis,  and  the  other  the  anterior  inferior 
angle  called  the  processus  vocalis. 

The  Thyroid  Cartilage  makes  up  the  greater  part  of  the  frame- 
work of  the  larynx.  It  consists  essentially  of  two  large  ala'  joined  to- 
gether in  front,  but  separated  posteriorly  by  the  interposition  of  the 
posterior  lamina  of  the  cricoid  and  of  the  two  arytenoid  cartilages. 
The  anterior  junction  involves  only  the  lower  two-thirds  of  the  whole 
height  of  the  ahe,  leaving  a  well-marked  notch  in  the  median  line.  At 
the  bottom  of  this  notch,  the  thyroid  cartilage  forms  the  most  anterior 
portion  of  the  larynx,  and  the  prominence  due  to  its  projection  is 
called  the  pomiini  Adami.  There  is  great  variation  in  the  angle  of  the 
junction  of  the  two  cartilages.  In  infants  it  is  more  of  a  curve  than  an 
an.irle,  while  the  average  for  the  adult  male  is  about  !H)  and  for  the  adult 
female  almost  120  .  The  superior  border  of  the  ala  is  convex  upward, 
while  the  lower  border  is  almost  straight.  The  posterior  free  edge 
of  each  ala  is  prolonged  upward  almost  to  the  hyoid  hone,  form- 
ing the  superior  cornii  and  downward  to  the  articulation  facet  on 
the  side  of  the  cricoid  forming  the  inferior  cornii.  <  )n  the  exter- 
nal surface  of  each  ala  somewhat  posterior  to  its  middle  is  a 
rid.u'e  runiiin.u1  diagonally  from  above,  behind,  downward  and  forward. 
It  is  usually  spoken  of  as  the  oblique  line  and  begins  above  at  a  prom- 
inence just  below  the  superior  border  of  the  ala  called  the  superior 


Sl'HdlCAI.  ANATOMY  OF  THK   IMIAUYNX.   LARYNX,  AND    NKCK. 


tubercle.  It  ends  on  the  inferior  border  in  another  prominence  called 
the  inferior  tubercle. 

The  Epiglottic  Cartilage  is  a  thin  lamina  of  yellow  elastic  carti- 
lage shaped  somewhat  like  a  broad  and  warped  paddle,  with  its  handle 
below  terminating  in  the  strong  thyroepiglott ic  ligament.  Its  surface 
is  irregularly  indented  by  depressions  and  there  are  numerous  perfo- 
rations running  through  the  cartilage.  Its  upper  end  is  free,  rising 
just  behind  the  base  of  the  tongue. 

The  Lesser  Cartilages  of  the  larynx  are  six  in  number.  The  two 
cartilagines  triticea4  are  small  nodules  situated  just  above  the  superior 
cornu  of  the  thyroid  cartilage  in  the  lateral  thyrohyoid  ligament.  Tlie 
cartilages  of  Santorini  or  the  corniciilate  cartilages,  two  in  number, 
are  perched  on  the  apices  of  the  arytenoid  cartilages  and  are  enclosed 
in  the  posterior  part  of  the  arytenoepiglottic  fold  of  mucous  membrane. 
In  this  same  fold,  immediately  external  to  the  cartilages  of  Santorini, 
are  the  cartilages  of  \Vrisberg  or  the  cuneiform  cartilages.  They  are 
inconstant  structures  but  generally  ])resent. 

Articulations  and  Ligaments  of  the  Larynx. 

The  laryngeal  joints  with  their  ligaments  form  one  of  the  most 
interesting  anatomic  features  of  the  larynx. 

Joints. — The  cricothyroid  joints  are  diarthrodial  with  a  pivotal 
and  also  a  gliding  movement.  The  circular  facets  on  the  internal  sur- 
face of  the  inferior  cornu  of  the  thyroid  cartilage  are  bound  fast  by  a 
capsular  ligament  to  the  corresponding'  slightly  elevate<l  circular  facets 
on  the  sides  of  the  cricoid  cartilage.  The  ])osterior  part  of  the  capsular 
ligament  is  strengthened  by  a  ligamentous  thickening.  The  crieoaryte- 
noid  .joints  are  more  complicated  but  are  also  diarthrodial.  They,  too, 
possess  a  pivotal  movement  as  well  as  a  lateral  gliding  motion,  and.  ac- 
cording to  some  authorities,  a  slight  anteroposterior  rocking  motion. 
The  articular  facet  of  the  cricoid  is  convex  while  that  of  the  arytenoid 
is  concave.  Both  articular  surfaces  are  elliptical  and  they  never  accu- 
rately coincide  with  one  another.  There  is  a  distinct  capsular  ligament 
which  is  strengthened  posteriorly  by  a  prominent  band,  which  limits 
the  anterior  rocking  motion  or  displacement  of  the  arytenoid  cartilage. 
The  lateral  gliding  motion  of  this  joint,  permits  the  two  arytenoid  car- 
tilages to  approach  one  another  or  separate,  thus  closing  or  opening  the 
posterior  third  of  the  glottic  chink.  The  pivotal  movement  allows  the 
vocal  process  to  move  toward  or  away  from  the  median  line  causing 
adduction  or  abduction  of  the  vocal  cords. 

There  are  two  important  membranes  in  the  larynx,  the  cricothy- 


1 4  OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AXD    EAR. 

void  and  the  thyrohyoid.  These  lie  in  the  intervals  between  the  carti- 
lages as  their  names  designate. 

The  Cricothyroid  Membrane  is  an  important  structure  and  con- 
sists of  three  portions;  two  lateral  divisions  and  a  central.  These  di- 
visions are  all  attached  below  to  the  upper  border  of  the  arch  of  the 
cricoid  cartilage.  Their  upper  attachments,  however,  are  very  dif- 
ferent. The  central  portion  which  is  somewhat  triangular  in  shape, 
is  strong,  tense,  and  elastic.  The  base  is  attached  to  the  upper  border 
of  the  anterior  part  of  the  cricoid  arch  and  the  narrowed  top  to  the 
lower  border  of  the  thyroid  cartilage.  The  lateral  portions  form  the 
side  walls  of  the  snbglottic  part  of  the  larynx  and  are  lined  internally 
only  with  mucous  membrane.  They  arise  below  from  the  upper  border 
of  the  cricoid  cartilage  and  passing  internally  to  the  ahr  of  the  thyroid 
find  their  upper  termination  in  the  whole  of  the  length  of  the  inferior 
thyroarytenoid  ligaments,  the  supporting  band  of  the  true  cords.  In 
front,  the  thyrohyoid  membrane  is  also  attached  to  the  inner  surface 
of  the  thyroid  ahr  near  the  notch,  and  behind  to  the  vocal  processes  of 
the  arytenoid  cartilages.  The  lateral  cricoarytenoid  and  thyroaryte- 
noid muscles  lie  directly  on  the  outer  surface  of  the  lateral  part  of 
the  cricothyroid  membrane. 

The  Thyrohyoid  Membrane  is  attached  along  the  upper  border  of 
the  thyroid  cartilage  and  to  the  internal  surface  of  the  hyoid  bone.  Its 
central  or  anterior  portion  is  thick  and  elastic  and  forms  the  median 
thyrohyoid  ligament.  This  ligament  is  attached  below  to  the  thyroid 
notch  and  above  to  the  upper  margin  of  the  posterior  surface  of  the 
hyoid  bone.  Where  the  ligament  passes  behind  the  bone  a  bursa  is 
generally  found  separating  the  two.  Posteriorly  the  hyoid  membrane 
terminates  in  a  strong  cord-like  ligament;  the  lateral  thyrohyoid  liga- 
ment. This  ligament  runs  from  the  tip  of  the  great  conm  of  the  hyoid 
bone  to  the  extremity  of  the  superior  conm  of  the  thyroid  cartilage. 
It  contains  the  small  cartilago  triticea.  The  inner  surface  of  the  thyro- 
hyoid  membrane  is  covered  by  the  mucous  membrane  of  the  pharynx, 
while  the  epiglottis  is  separated  from  the  median  thyrohyoid  ligament 
by  a  cushion  of  fat. 

There  arc  two  thyroarytenoid  ligaments,  the  inferior  and  supe- 
rior. 

The  Inferior  Thyroarytenoid  Ligament  is  really  the  thickened  up- 
per border  of  the  hiteral  parts  of  the  cricotliyroid  membrane.  It  is 
the  supporting  ligament  of  the  true  vocal  cords  and  is  attached  ante- 
riorly to  the  middle  of  the  thyroid  angle  close  to  its  fellow,  while  pos- 
teriorly it  Mends  with  the  vocal  process  of  the  arytenoid  cartilage. 


Sri{<;i('AI,  A  NATO  .MY   OK  TIIK   IMIAKYNX,  LAKYN.X,  AND   NKCK. 


This  ligament  contains  numerous  yellow  clastic  fibres  and  sometimes 
near  its  anterior  end  a  small  nodule  of  elastic  cartilage. 

The  Superior  Thyroarytenoid  Ligament  is  a  much  less  important 
structure  and  while  thinner  and  weaker  is  longer  than  the  inferior. 
It  supports  the  ventricular  bands.  It  is  attached  anteriorly  to  the  thy- 
roid angle;  just  above  the  inferior  and  posteriorly  to  a  small  tubercle 
on  the  anterior  surface  of  the  arytenoid  just  above  the  processus  vo- 
calis.  There  are  a  few  elastic  fibres  in  it  but  it  is  mostly  composed  of 
fibrous  tissue,  which  is  more  or  less  continuous  with  the  supporting 
fibres  of  the  arytenoepiglottic  fold. 

Ligaments  of  the  Epiglottis. — The  epiglottis  is  fastened  to  the 
body  of  the  hyoid  bone  by  an  irregular  broad  elastic  band,  the  hyoepig- 
lottic  ligament.  From  the  inferior  narrowed  end  of  the  epiglottis  a 


l  - 


8 
9 
10 

^\*^!!^^^r 

11 


Fig.  64. 
The  lateral  external  surface  of  the  larynx. 

1,  Superior  cornu  of  thyroid;  2,  Posterior  lamina  of  cricoid;  ?>,  Inferior 
cornu  of  thyroid;  4,  Strengthening  band  of  capsular  ligament;  5,  First 
ring  of  the  trachea;  6,  Ala  of  thyroid;  7,  Superior  tubercle  of  thyroid:  8. 
Oblique  line  of  thyroid:  9,  Central  part  of  cricothyroid  membrane:  10. 
Oblique  portion  of  cricothyroid  muscle;  11,  Horizontal  portion  of  the  crico- 
thyroid muscle. 

strong  thick  ligament,  composed  of  elastic  tissue,  the  thyroepigiottic 
ligament,  runs  to  the  posterior  surface  of  the  thyroid  angle  just  below 
the  notch.  Besides  these  two  true  ligaments  the  epiglottis  is  fastened 
to  the  tongue  by  three  folds  of  mucous  membrane,  the  median  and  two 
lateral  glossoepi glottic  folds.  These  have  already  been  described. 

The  Muscles  of  the  Larynx. 

Under  this  head  will  be  described  only  those  muscles  which  have 
both  their  origin  and  insertion  in  some  part  of  the  larynx  itself.   AVhile 


76  OPERATIVE    SURCERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

some  of  them  are  contained  entirely  within  the  cavity  bounded  by  the 
ala  of  the  thyroid,  the  ericothyroid,  the  arytenoid  and  the  posterior 
ericoarytenoid  arc  on  the  external  surface  of  the  larynx  proper. 
The  Cricothyroid  Muscle  arises  from  the  anterior  surface  of  the 
cricoid  arch  and  the  lower  adjoining  border  and  radiating  upward  and 
backward  usually  separates  more  or  less  distinctly  into  two  divisions. 
The  anterior  of  these  divisions  crosses  the  ericothyroid  interval  more 
perpendicularly  than  the  posterior  and  is  inserted  into  the  lower  ed^e 
and  the  neighboring  inner  surface  of  the  ala  of  the  thyroid.  The  pos- 


9 

10 

11 
12 

13 
14 


Fig.   65. 
The   muscles   of  the   laryngoal    wall   on    the   posterior   aspect. 

1,  Arytenoepiglottic  muscle;  2,  Cartilage  of  Santorini;  ?>,  Arytenoideiis 
obliquus  muscle;  4,  Aryteuoideus  transversus  muscle;  F>,  Cricoarytenoideus 
posticus  muscle;  6,  Epiglottis;  7,  Retrohyoid  bursa;  8,  Thyrohyoid  muscle: 
!».  Thyroepiglottic  muscle;  Id,  Thyroid  cartilage;  11,  Thyroarytenoideus 
muscle;  12,  Cricoarytenoideus  lateralis  muscle;  13,  Articular  facet  for 
inferior  cornua  of  thyroid;  14,  Cricoid  cartilage. 

tcrior  division  is  inserted  into  the  anterior  aspect  of  the  inferior  cornu 
of  the  thyroid.  The  cricot  hyroid  is  sometimes  rather  closely  associ- 
ated with  the  inferior  constrictor  of  the  pharynx. 

The  Posterior  Cricoarytenoid  Muscle  arises  by  a  broad  base  from 
a  depression  which  covers  almost  the  entire  half  of  the  posterior  sur- 
face of  the  crieoid  lamina.  Its  fibres,  con  vermin  14-  as  they  ascend  in  a 
slightly  lateral  direction,  arc  inserted  into  the  posterior  surface  of 
the  muscular  process  of  the  arytenoid. 

The  Arytenoid  Muscle  consists  of  two  parts,  a  superficial  oblique 
layer  and  a  deep  transverse  layer. 


Sl'HCICAL  ANATOMY   OF  THK    I'llAltYXX,   LAHYXX,  AXI)    XKCK.  /  / 

The  oblique  arytenoid  is  a  paired  muscle,  one  muscle  crossing  the 
other  in  the  median  line  on  the  posterior  aspect  of  the  larynx.  Kach 
muscle  consists  of  a  narrow  bundle  which  arises  from  the  posterior 
side  of  the  muscular  process  of  the  arytenoid  and,  running  obliquely 
upward,  passes  around  the  outer  side  of  the  summit  of  the  opposite 
arytenoid  cartilage.  Some  of  the  fibres  are  here  inserted  into  the  ary- 
teuoid  but  many  continue  upward  into  the  aryteuoepiglottic  fold,  as 
the  arytenoepiglottic  muscle,  and  are  joined  near  the  epiglottis  by 
fibres  from  the  thyroepiglottie  muscle. 

The  transverse  arytenoid  is  a  transverse  sheet  of  muscle  beneath 
the  oblique,  stretching  between  the  posterior  aspect  of  the  outer  bor- 
der of  each  arytenoid  cartilage.  Some  of  the  fibres  are  apparently 
continuous  with  tlie  fibres  of  the  thyroarytenoid. 

The  Lateral  Cricoarytenoid  is  somewhat  smaller  than  the  poste- 
rior. It  springs  by  a  rather  broad  base  from  about  the  middle  third 
of  the  upper  border  of  the  lateral  part  of  the  cricoid  arch  and  also 
from  the  neighboring  part  of  the  cricothyroid  membrane.  Its  fibres 
running  backward  and  upward  converge  to  be  inserted  into  the  front 
of  the  muscular  process  of  the  arytenoid  cartilage. 

The  Thyroarytenoid  Muscle  consists  of  two  parts,  an  external  and 
an  internal,  which,  however,  are  closely  blended.  A  large  part  of  the 
lower  border  of  this  muscle  is  closely  associated  with  the  upper  border 
of  the  lateral  cricoarytenoid. 

The  External  Thyroarytenoid  Muscle  is  a  broad  sheet  just  within 
the  ala  of  the  thyroid  cartilage  and  spreads  from  the  upper  surface  of 
the  lateral  cricoarytenoid  to  above  the  level  of  the  vocal  cord.  It  arises 
in  front  from  the  lower  half  of  the  thyroid  ala  close  to  the  angle  and 
also  from  a  portion  of  the  lateral  cricothyroid  membrane.  Its  fibres 
running  backward  parallel  with  the  vocal  cord  are  inserted  for  the 
greater  part  into  the  muscular  process  of  the  arytenoid  cartilage.  A 
few  fibres  pass  around  this  cartilage  and  are  continuous  with  the  trans- 
verse fibres  of  the  arytenoid. 

The  Thyroepiglottic  Muscle  is  really  an  off-shoot  from  the  upper 
border  of  the  external  thyroarytenoid  which  turns  upward  to  be  in- 
serted into  the  upper  part  of  the  arytenoepiglottic  fold  and  the  free 
margin  of  the  epiglottis. 

The  Internal  Thyroarytenoid  Muscle  is  triangular  in  cross  sec- 
tion and  closely  associated  with  the  vocal  cord.  It  arises  from  the 
thyroid  angle  in  front  and  is  inserted  first  by  several  muscular  slips 
into  the  vocal  cord  itself  and  second  into  the  outer  side  of  the  vocal 
process  and  adjoining  outer  surface  of  the  arytenoid  cartilage. 


78 


OPERATIVE    SUROERY    OF    THE    XOSE,    THROAT,    AXD    EAR. 


The  portion  of  the  muscle  which  is  inserted  into  the  cord  is  some- 
times spoken  of  as  the  aryvocalis  muscle. 

The  Action  of  the  Muscles  of  the  larynx  is  concerned  both  with  the 
movement  of  the  vocal  cords  and  the  closure  of  the  upper  Jaryngeal 
aperture. 

The  cricothyroid  acts  as  a  tensor  of  the  vocal  cords  by  tilting  the 
thyroid  cartilage  downward  and  forward  (oblique  fibres)  and  by  pull- 
ing the  cartilage  as  a  whole  slightly  forward  (transverse  fibres).  As 
the  arytenoids  are  prevented  from  riding  forward  on  the  to].)  of  the 
cricoid  lamina,  this  forward  tilting  of  the  thyroid  cartilage  must  put 
tension  on  the  vocal  cords.  In  opposition  to  this  action  of  the  crico- 
thyroid, the  thyroarytenoid  relaxes  the  vocal  cords  by  approximating 
the  angle  of  the  thyroid  cartilage  with  the  arytenoid  cartilage.  While 


Fig.  66. 
Diagrams   illustrating   closed   and    open    glottis. 

1,  Thyroid  cartilage;  2,  Thyroarytenoideus  interims;  r>,  Crieoarytenoi- 
dens  lateralis;  4,  Arytenoid  cartilage:  ,r>.  Cricoarytenoideus  posticus;  *>, 
Arytenoidens  transversus;  7,  Cricoid  cartilage;  8,  Thyroid  cartilage; 
9,  Thyroarytenoideus  interims;  10,  Cricoarytenoideus  lateralis;  11,  Aryte- 
noid cartilage;  12,  Cricoarytenoideus  posticus;  V.\,  Arytenoideus  trans- 
versus; 14,  Cricoid  cartilage. 

the  tliyroarytonoic]  as  a  whole,  relaxes  the  whole  vocal  cord,  it  is  prob- 
able that  the  falsetto  voice  results  from  a  partial  contraction  of  the  in- 
ternal thyroarytenoid  by  relaxing  only  a  portion  of  the  cord  while  the 
crirothyroid  makes  the  remaining  part  of  the  cord  tense,  the  tense 
portion  only  being  capable  of  vibration.  The  posterior  erieoarytenoid 
muscle  by  rotating  the  arytenoid  cartilage  so  that  the  vocal  process 
turns  outward,  is  the  abductor  of  the  cords  while  the  lateral  cricoaryte- 
noid  muscle  by  rotating  it  in  the  opposite  direction  becomes  the  ad- 
< luct or  of  the  cords. 

The   transverse   arytenoid    muscles    bring  the   central    sides   of   the 
arytenoid   cartilages  together  and   thus  complete   the    closure    of    tlm 


glottic-  chink  after  the  vocal  cords  proper  have  boon  approximated  by 
tlio  inward  rotation  of  the  arytonoid  cartilage. 

The  closure  of  the  superior  laryngoal  aperture  during  swallow- 
ing is  accomplished  chiefly  by  the  oblique  portion  of  the  arytonoid  act- 
ing in  concert  with  the  arytenoepiglottic  muscles.  rriio  transverse 
arytenoid  with  the  thyroarytenoid  muscles  probably  aid  in  the  closure 
by  approximating1  the  arytenoid  cartilages  and  compressing  the  sides 
of  the  larynx  at  about  the  position  of  the  false  vocal  cords.  The  su- 
perior aperture  when  closed  presents  a  tkT"  shaped  fissure  with  the 
top  of  the  "T"  approximately  parallel  with  the  transverse  axis  of  the 
epiglottis  and  the  stem  running  between  the  two  arytonoid  bodies. 
The  muscles  therefore  which  affect  this  closure  must  bo  looked  upon 
in  effect  as  true  sphincters. 

The  Nerve  Supply  of  the  Larynx. 

The  nerves  supplying  the  larynx  are  two  in  number,  and  both  are 
branches  of  the  pueumogastric  or  vagus. 

The  Superior  Laryngeal  Nerve  leaves  the  vagus  high  up  in  the 
neck,  and  passes  obliquely  downward  and  forward  on  the  inner  side  of 
the  internal  and  external  carotid  arteries.  On  approaching  the  larynx. 
it  divides  into  two  unequal  parts,  a  larger  internal,  and  a  smaller  ex- 
ternal branch. 

The  Internal  Laryngeal  Nerve  passes  between  the  middle  and  in- 
ferior pharyngeal  constrictors  and  roaches  the  interior  of  the  larynx 
by  penetrating  the  thyrohyoid  membrane.  Sensation  is  supplied  by 
this  nerve  to  the  mucous  membrane  of  the  larynx  from  the  epiglottis 
down  to  the  upper  part  of  the  trachea.  This  nerve  probably  also  con- 
tains vasomotor  and  secretory  fibres,  which  it  supplies  to  the  whole  of 
the  laryngeal  mucous  membrane. 

The  External  Laryngeal  Nerve  runs  downward  on  the  external 
surface  of  the  inferior  constrictor,  ending  at  the  cricothyroid  muscle 
which  it  supplies.  Branches  arc  sent  to  the  inferior  constrictor  muscle 
and  probably,  a  few  motor  twigs  pass  to  the  arytonoid. 

The  Recurrent  or  Inferior  Laryngeal  Nerve  leaves  the  pnounio- 
gastrie  in  the  lower  part  of  the  neck,  and  turns  upward  to  supply  all 
of  the  intrinsic  muscles  of  the  larynx  except  the  cricothyroid.  and 
part  of  the  arytenoid. 

THE  LYMPHATIC  SYSTEM  OF  THE  NECK. 

The  cervical  lymphatic  nodes  are  divided  into  two  main  groups, 
the  superficial  or  collecting  nodes  and  the  dee])  or  terminal  nodes.  The 


OPERATIVE    STRCERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

superficial  group  is  arranged  as  a  sort  of  a  collar  around  the  upper 
part  of  the  neck  with  a  few  irregular  extensions.  This  pericervical 
circle  is  composed  of  the  following  subgroups: 

1.     Suboceipital  group  and  aberrant  glands  of  the  nape  of  the  neck. 

±     Mastoid  group. 

.'!.      Parotid  and  subparoticl  group. 

4.      Snhniaxillary  group  with  the  facial  glands  as  an  off-shoot. 

f>.      Suhmental  group. 

(i.     Retropharyngeal  group. 

The  Suboceipital  Group  of  glands  are  rather  inconstant  struc- 
tures varying  from  one  to  three  in  number  and  usually  are  placed  on 
the  occipital  insertion  of  the  complexus  muscle  just  external  to  the  ex- 
ternal border  of  the  trape/ius.  They  receive  the  lymph  vessels  from  the 
back  of  the  head  and  their  efferent  vessels  terminate  in  the  highest 
nodes  of  the  substernomastoid  group. 

The  Mastoid  Group  or  retroauricular  glands,  generally  two  in  num- 
ber, lie  on  the  mastoid  insertion  of  the  sternomastoid.  These  glands 
receive  their  afferent  vessels  from  the  temporal  portion  of  the  hairy 
seal)),  from  the  internal  surface  of  the  auricle  except  the  lobule  and 
from  the  posterior  surface  of  the  external  auditory  meatus.  They 
empty  into  the  highest  glands  of  the  dee])  lateral  chain. 

The  Parotid  Group  consists  of  glands  in  the  parotid  space  either 
external  to  the  gland,  the  superficial  nodes,  or  in  the  actual  substance 
of  the  parotid,  the  deep  nodes.  The  deeper  parotid  nodes  are  scat- 
tered throughout  the  substance  of  the  parotid  but  for  the  most  part 
are  grouped  around  the  external  carotid  artery.  They  are  quite  nu- 
merous though  some  are  very  small  and  can  be  seen  only  by  the  micro- 
scope. These  glands  receive  afferent  vessels  from  the  external  surface 
of  the  auricle,  from  the  external  auditory  meatus,  from  the  tympanum, 
from  the  skin  of  the  temporal  and  frontal  regions  and  possibly  also 
from  the  eyelids  and  base  of  the  nose.  It  is  possible  that  at  times 
they  drain  the  nasal  fossa1  also  and  the  posterior  part  of  the  alveolar 
border  of  the  superior  maxilla.  The  elTerents  run  into  the  upper  sub- 
sternomastoid  glands  near  the  exit  of  the  external  jugular  vein  from 
the  parotid. 

The  Subparotid  Glands  belong  in  reality  to  the  parotid  group  but 
are  placed  beneath  the  parotid,  between  it  and  the  plmryiigeal  wall  in 
the  lateropharyngeal  space.  Suppurative  inflammation  of  these  glands 
ii'ivcs  rise  to  lateral  pharyngeal  abscesses.  Their  afferents  come  from 
the  nasal  fossa-,  from  the  nasopharynx  and  from  the  Kiistachian,  while 
their  elTerents  pass  to  the  upper  glands  of  the  deep  cervical  chain. 


S] 

The  Submaxillary  Group  consists  of  fVotn  three  to  six  nodes  situ 
ated  along  the  length  of,  and  immediately  beneath,  the  lower  border 
of  the  mandible.  The  largest  of  the  group  is  generally  found  neat'  the 
facial  artery.  These  glands  are  jnst  beneath  the  fascia  and  are  more 
or  less  intimately  associated  with  the  upper  border  of  the  submaxil- 
lary  salivary  inland.  Their  afferent  vessels  come  from  the  external 
nose,  the  cheek,  from  the  upper  and  the  external  part  of  the  lower  lip, 
from  practically  the  whole  of  the  gums  and  from  the  anterior  third  of 
the  sides  of  the  tongue.  The  efferent  vessels  running  over  the  surface 
of  the  submaxillary  salivary  glands  empty  generally  into  the  glands 
of  the  deep  cervical  chain  near  the  bifurcation  of  the  common  carotid. 
They  may  at  times  pass  to  glands  further  down  the  chain. 

The  Facial  Glands  are  small  inconstant  structures  found  in  the 
course  of  the  afferent  vessels  leading  to  the  submaxillary  nodes.  They 
generally  form  three  groups.  The  inferior  or  supramaxillary  rest  on 
the  jaw  just  in  front  of  the  masseter  muscle.  Occasionally  there  is  a 
gland  immediately  on  the  edge  of  the  jaw  at  this  position  called  the 
inframaxillary  gland.  A  less  frequent  group  of  glands  is  the  middle 
or  buccinator  group  on  the  external  surface  of  the  buccinator  mus- 
cle, All  of  these  buccinator  glands  lie  outside  of  the  bnccal  fascia. 
There  may,  however,  be  a  subfascial  gland  or  a  submucous  gland.  The 
third  group  is  still  less  constant  and  is  situated  jnst  to  one  side  of  th." 
nose. 

The  Submental  Group  consisting  of  from  one  to  four  glands  are 
found  in  the  triangle  bounded  by  the  anterior  bellies  of  the  two  di- 
gastric muscles  and  the  hyoid  bone.  The  afferent  vessels  of  this  group 
are  from  the  skin  of  the  chin  from  the  centre  portion  of  the  lower  lip 
and  from  the  mucous  membrane  covering  the  external  portion  of  the 
alveolus,  from  the  floor  of  the  mouth  and  from  the  tip  of  the  tongue. 
The  efferent  vessels  run  either  to  the  submaxillary  gland  or  directly 
downward  to  a  node  of  the  deep  cervical  chain  situated  on  the  internal 
jugular  vein  just  above  where  it  is  crossed  by  the  omohyoid. 

The  Retropharyngeal  Group  consisting  generally  of  two  glands  is 
placed  back  of  the  posterior  pharyngeal  wall  near  its  outer  edge  being 
almost  '2  cm.  from  the  median  line.  These  glands  are  separated  from  the 
atlas  by  the  rectus  capitis  anticus  major  muscle  and  are  in  rather  close 
relation  externally  with  the  sheath  of  the  great  vessels  of  the  neck. 
Suppurative  inflammation  of  these  nodes  leads  to  retropharyngeal  ab- 
scess. In  this  case  the  abscess  starts  laterally  but  being  limited  ex- 
ternally by  the  fascia  covering  the  vessels  enlarges  medianward.  Oc- 
casionally there  are  small  inconstant  nodes  back  of  the  pharyngeal 
wall  almost  in  the  median  line.  The  retropharyngeal  glands  receive- 


82  OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 

their  afferents  from  the  mucous  membrane  of  the  nasal  fosstv  and  ac- 
cessory sinuses,  from  the  nasopharynx  including  tlie  pharyngeal  ton- 
sil, from  the  region  of  the  Eustachian  tube  and  possibly  from  a  part 
of  the  tympanic  cavity.  It  must  be  said,  however,  that  the  retrophar- 
yngeal  lymphatic  glands  are  only  interrupting  nodes  placed  on  the  col- 
lecting lymphatics  as  they  pass  from  the  upper  part  of  the  back  of  the 
throat  to  the  posterior  group  of  the  deep  cervical  chain.  The  afferent 
lymph  vessels  of  the  retropharyngeal  lymph  glands  follow  the  same 
general  course  as  those  efferent*,  which  come  directly  from  the  poste- 
rior pharyngeal  wall  and  pass  behind  the  great  vessels  of  the  neck  to 
reach  the  posterior  edge  of  the  sternomastoid  muscle,  and  empty  into 
the  upper  nodes  of  the  posterior  group  of  the  deep  cervical  chain. 


9 

10 


11 


13 


6 

Fig.  »J7. 
Dissection  showing  the  upper  deep  cervical  lymph  ludes. 

1,  Masseter  muscle;  "2,  Facial  artery;  I',,  Submaxillary  gland;  4.  llypoglos- 
sal  nerve;  ">,  Digastric  (posterior  belly)  and  stylohyoid  muscles;  t'». 
Anterior  group  of  the  deep  cervical  lymph  nodes;  7,  Facial  nerve;  8, 
Hxternal  jugular  lymph  node;  !»,  Sternomastoid  muscle;  10,  Posterior  group 
of  the  deep  cervical  lymph  nodes;  11,  Spinal  accessory  nerve;  11'.  Sterno- 
mastoid artery;  1.'',,  Internal  jugular  vein. 

The  Descending  Cervical  chain  of  lymph  nodes  consists  of  two  sets 
of  u'lands,  the  deep  cervical  chain  and  several  more  or  less  important 
secondary  and  more  superficial  chains.  The  deep  glands  situated  on 
each  side  of  the  neck  comprise  from  fifteen  to  thirty  nodes  on  an  aver- 
age, although  these  fiu'iires  do  not  represent  the  extremes  of  variation. 
This  u'roiip  of  u'lands  is  variously  termed  the  carotid  chain,  the  sub- 


SURGICAL  ANATOMY   ()!•'  THE   PHARYNX,  LARYNX,  AND    NKCK.  SI] 

sternomastoid  group,  or  the  deep  lateral  glands  of  the  neck,  and  may 
theoretically  and  clinically  be  divided  into  two  groups,  although  ana- 
tomically they  are  closely  associated.  They  extend  from  just  beneath 
the  ear  downward  under  the  sternocleidomastoid  muscle,  generally 
only  as  far  as  the  point  where  the  omohyoid  crosses  the  vessels  and 
nerves,  but  occasionally  reaching  as  far  as  the  junction  of  the  internal 
jugular  and  subclavian  vein.  The  more  superficial  division  of  the  deep 
lateral  chain  lies  posteriorly  and  is  called  the  external  group.  The 
external  glands  are  generally  small,  and  placed  in  part  beneath  the 
posterior  border  of  the  sternocleidomastoid,  and  occasionally  extend  so 
far  down  the  anterior  border  of  the  trape/ius  muscle  as  to  come  into 
rather  close  relation  with  the  supraclavicular  glands.  They  rest  rather 
irregularly  distributed,  on  the  external  surface  of  the  splenius,  levator 
anguli  scapuhv,  cervical  plexus  and  the  spinal  accessory  nerve. 

The  anterior  or  deep  division  of  the  main  group  is  placed  directly 
over  the  great  vessels  of  the  neck,  and  is  termed  the  internal  jugular 
group.  These  nodes  are  situated  beneath  the  anterior  border  of  the 
sternocleidomastoid  muscle,  and  when  enlarged  may  be  forced  anteri- 
orly until  some  of  them  appear  immediately  below  the  angle  of  the  jaw. 
One  or  two  large  glands  are  constantly  found  below  the  posterior  belly 
of  the  digastric,  just  above  the  spot  where  the  thyrolingual-facial  vein 
opens  into  the  internal  jugular.  These  nodes  receive  lymphatics  from 
the  tongue  while  immediately  above  the  digastric  is  a  large  node  which 
drains  the  tonsil  and  surrounding  region.  A  few  glands  are  sometimes, 
found  between  the  internal  jugular  and  the  prevertebral  muscles. 

The  Accessory  or  Superficial  Descending  Cervical  chain  consists 
of  four  groups,  the  external  jugular  chain,  the  superficial  anterior  cer- 
vical chain,  the  deep  anterior  cervical  chain,  and  the  recurrent  chain. 

The  EXTERNAL  JrtiULAR  CHAIN  consists  usually  of  two  or  three 
nodes  resting  on  the  external  surface  of  the  sternomastoid  just  below 
the  parotid  gland.  Occasionally  one  or  two  nodes  are  found  further 
down  along  the  course  of  the  veins.  Their  afferent  vessels  come  from 
the  auricle  and  parotid  region  and  their  efferent  vessels  terminate  in 
the  upper  nodes  of  the  deep  cervical  chain.  It  is  claimed  that  some- 
times an  efferent  vessel  from  these  glands  may  follow  along  the  course 
of  the  external  jugular  vein  and  empty  into  the  supraclavicular  glands. 

The  SUPERFICIAL  ANTERIOR  CERVICAL  CHAIN  consists  of  two  or  three 
inconstant  nodes  on  the  anterior  jugular  vein. 

The  DEEP  ANTERIOR  CKRYICAL  CHAIN  may  be  divided  into  three  dis- 
tinct groups:  the  prelaryngeal,  the  prethyroid  and  pretracheal. 

The  prelaryngeal  group  consists  of  one.  two  or  three  inconstant 
glands  most  frequently  found  in  the  triangular  space  bounded  by  the 


84  OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 

two  cricothyroid  muscles.  When  present  their  afferent*  come  from 
the  middle  lymphatic  pedicle  of  the  larynx.  Their  efferent*  may  run 
either  to  the  pretracheal  nodes  or  to  the  lower  nodes  of  the  deep  lateral 
chain. 

The  prethyroid  glands  are  usually  absent. 

The  pretracheal  group  is  usually  present  and  consists  of  one  or 
more  very  small  nodes.  Their  afferent*  come  from  the  thyroid  body 
and  the  prelaryngeal  nodes  and  their  efferent*  terminate  in  the  lower 
node*  of  the  deep  lateral  chain. 

The  RECURRENT  OHAIX  consists  of  from  three  to  six  minute  nodes 
along1  the  course  of  the  recurrent  laryngeal  nerves.  Their  afferent  ves- 
sels come  from  the  inferior  pedicle  of  the  larynx,  from  the  neighbor- 
ing region  of  the  trachea  and  esophagus  and  a  part  of  the  thyroid  body. 
It  is  important  to  remember  that  the  efferent  vessels  of  this  chain 
terminate  in  the  inferior  node*  of  the  deep  lateral  chain  instead  of  pro- 
ceeding downward  to  the  mediastinal  glands.  It  i*,  however,  possible 
that  occasionally  an  efferent  from  these  nodes  passes  directly  to  the 
superclavicular  glands. 

The  Supraclavicular  Group  of  lymph  glands  occupies  the  supra- 
clavicular  or  subclavian  triangle.  These  glands  are  generally  very 
numerous  and  are  imbedded  in  the  adipose  tissue  found  in  this  triangle 
the  so-called  "fettpolster"  of  Merkle.  In  the  upper  part  of  the  triangle 
they  are  just  beneath  the  superficial  cervical  fascia  and  rest  on  the 
splenins,  levator  anguli  scapuhr  and  scalenus  muscles.  Also  they 
hold  important  surgical  relations  with  some  of  the  lower 
branches  of  the  cervical  plexus  which  supply  the  trapezius  and  with 
the  ascending  cervical  artery.  The  more  inferior  glands  of  this  group 
are  in  greater  part  placed  in  front  of  the  middle  layer  of  cervical  fascia 
lying  very  close  to  the  terminal  subfascial  portion  of  the  external  jug- 
ular and  descending  branches  of  the  cervical  plexus.  Some  nodes 
more  deeply  placed  are  found  behind  the  oniohyoid  and  the  middle 
layer  of  cervical  fascia  being  just  in  front  of  the  brachial  plexus  and 
the  third  portion  of  the  subclavian. 

The  majority  of  authors  place  this  chain  of  glands  as  an  auxiliary 
group  of  the  deep  cervical  chain,  but  my  own  researches  have  led  me 
to  believe  that  the  supraclavicular  nodes  rarely  show  any  anastomosis 
with  any  of  the  cervical  lymph  nodes.  This  is  a  most  important  ana- 
tomic feature  because  a  direct  connection  between  these  nodes  and  the 
cervical  lymph  glands  would  establish  the  necessary  link  in  the  lym- 
phatic chain  from  the  tonsils  to  the  apex  of  the  lung. 

The  alferents  of  the  su pracla  vicular  glands  come,  first  from  the 
posterior  part  of  the  scalp  and  from  the  muscles  of  the  neck,  second 


SUWilCAL  ANATOMY   OK  Tl  I  K   I'll  A  I!  V  X  X  ,   LAKYXX,  AND   NKCK.  S.J 

from  the  skin  of  the  pectoral  region,  third  from  tho  skin  of  the  arm 
over  the  cephalic  vein,  fourth  from  the  humeral  chain  of  the  axillary 
group  of  glands,  and  fifth  (doubted  by  some  authors)  from  the  parietal 
pleura  covering  the  apex  of  each  lung.  The  efferent  vessel  of  the 
supraclavicular  glands  generally  empties  into  the  jugular  trunk. 

The  jugular  lymphatic  trunk,  the  terminal  vessel  of  the  deep 
lateral  chain,  usually  terminates  on  the  right  side  in  the  angle  of  junc- 
tion of  the  internal  jugular  and  subclavian  veins.  On  the  left  side  it 
most  frequently  terminates  in  the  thoracic  duct. 

TOPOGRAPHIC    ANATOMY    OF    THE    ANTERIOR    CERVICAL 

TRIANGLE. 

Viewed  from  the  side,  the  neck  is  divided  by  the  sternocleido- 
mastoid  muscle  into  two  triangles,  an  anterior,  and  a  posterior  triangle. 
The  anterior  cervical  triangle  is  subdivided  into  a  digastric  (submaxil- 
lary),  a  carotid  (superior  carotid)  and  a  muscular  (inferior  carotid) 
triangle  by  the  digastric  and  omohyoid  muscles,  while  the  posterior 
triangle  is  divided  by  the  posterior  belly  of  the  omohyoid  into  the 
occipital  and  supraclavicular  triangles. 

The  skin  of  the  neck  is  loosely  attached  and  the  creases  and  folds 
formed  by  the  flexion  of  the  head  as  a  rule  run  from  above  and  behind 
obliquely  forward  and  downward.  It  is  important  to  remember  the 
direction  of  these  folds  as  incisions  heal  with  less  deformity  when 
made  either  in  the  fold  itself  or  parallel  with  its  course.  In  the  lower 
part  of  the  neck  the  folds  run  more  transverse,  and  the  incision  should 
then  be  less  oblique  following  the  direction  of  the  skin  fissures. 

Beneath  the  skin  is  the  superficial  fascia.  This  fascia  is  continu- 
ous with  that  of  the  head  and  chest,  and  contains  the  superficial  nerves 
and  blood  vessels,  none  of  which,  however,  have  any  great  surgical 
importance. 

Between  the  superficial  fascia  and  the  deep  fascia  is  placed  the 
Pilatysma  myoides  muscle.  This  muscle  is  a  thin  sheet  covering  the 
anterior  part  of  the  side  of  the  neck,  arising  from  the  deep  fascia  of 
the  pectoral  region  and  from  the  clavicle.  Its  fibres  extend  upward  and 
slightly  forward.  The  greater  part  of  the  muscle  is  inserted  into  the 
lower  border  of  the  jaw  but  some  of  the  fibres  are  continuous  with 
the  depressor  labii  inferioris,  the  depressor  anguli  oris,  and  the 
risorius.  The  anterior  fibres  meet  across  the  middle  line  just  below  the 
chin. 

Just  beneath  the  posterior  part  of  the  platysma  is  the  external 
jugular  vein.  The  line  of  this  vein  is  from  the  angle  of  the  jaw  to  the 


b6  OPERATIVE    SURtiERY    OF    THE    XOSE,    THROAT,    AND    EAR. 

middle  of  the  clavicle.  It  is  formed  by  the  junction  of  the  posterior 
auricular  vein  with  the  posterior  branch  of  the  temporomaxillary  vein. 
It  passes  downward  external  to  the  deep  fascia,  crossing  obliquely  over 
the  sternomastoicl  muscle,  and  pierces  the  deep  fascia  in  the  anterior 
part  of  the  suhclavian  triangle.  It  crosses  in  front  of  the  third  part 
of  the  suhclavian  artery  and  empties  into  the  subclavian  vein. 

Almost  immediately  posterior  to  the  vein  running  parallel  with  its 
upper  part  will  be  found  the  ii'reat  auricular  nerve.    This  nerve  is  the 


9 

10 

11 

12 
13 


Fig.  68. 
Superficial  dissection  of  the  carotid  triangle. 

1,  Masseter  muscle;  2,  Facial  artery;  ?,,  Submaxillary  gland;  4,  Jlypoglos- 
sal  nerve;  5,  Anterior  group  of  the  deep  cervical  lymph  nodes;  ti,  Superior 
thyroid  artery;  7,  Facial  nerve;  8,  Posterior  auricular  artery;  !),  External 
jugular  lymph  node;  10,  Posterior  belly  of  the  digastric  muscle;  11, 
Stcrnomastoid  muscle;  12,  Posterior  group  of  the  deep  cervical  lymph  nodes; 
13,  Spinal  accessory  nerve. 

largest  of  the  superficial,  or  cutaneous  branches  of  the  cervical  plexus, 
ll  pierces  the  deep  cervical  Fascia  just  above  the  middle  of  the  posterior 
border  of  the  stcrnomastoid  muscle  and  ascends  in  close  relation  with 
the  external  jugular  vein.  Immediately  beneath  the  ear  it  divides 
into  three  branches;  the  anterior  or  facial  branch  which  supplies  the 
skin  over  the  parotid  inland  and  anastomoses  in  the  substance  of  this 
inland  with  the  facial  nerve;  the  auricular  branch,  which  supplies  both 


Sl'KlilCAL  ANATOMY  OF  T1IK   I'HAHYNX,  LAKYNX,  AND    NKCK. 


sides  of  the  lower  part  of  the  pinna;  an<l  the  mastoid  branch,  which 
supplies  the  skin  of  the  scalp  behind  the  ear.  Above  the  anricularis 
maxims,  the  small  occipital  nerve,  a  branch  of  the  cervical  plexus  passes 
upward  along  the  posterior  border  of  the  sternomastoid.  .lust  below 
the  great  auricular  nerve  the  superficial  cervical  nerve  pierces  tin- 
dee])  fascia  and  passes  forward  and  transversely  over  the  sternomas- 
toid and  beneath  the  external  jugular  vein. 

The  deep  fascia  of  the  neck  invests  all  the  muscles  and  forms 
aponeurotic  coverings  for  the  esophagus,  pharynx  and  trachea,  cap- 
sules for  the  salivary  glands,  and  sheaths  for  the  larger  blood  vessels. 
This  fascia  is  attached  behind  to  the  ligamentmn  undue  and  the  spinal 
process  of  the  seventh  cervical  vertebra.  A  superficial  layer  passes 
forward,,  enveloping  the  trapczius  muscle  and  uniting  in  front  of  the 
muscle,  it  crosses  over  the  posterior  triangle  of  the  neck  to  envelope 
the  sternomastoid  muscle.  Above  it  is  attached  to  the  mastoid  process 
and  the  superior  curved  line  of  the  occipital  bone  and  below  to  the  clav- 
icle. From  the  anterior  edge  of  the  sternomastoid  muscle  it  continues 
forward  to  the  median  line  of  the  neck  in  a  single  layer.  In  the  front 
part  of  the  neck  the  upper  attachment  is  to  the  lower  border  of  the 
jaw,  the  styloid  process,  and  the  hyoid  bone. 

Below,  near  the  sternum,  it  divides  into  two  layers,  an  anterior  and 
a  posterior  which  are  attached  respectively  to  the  anterior  and  pos- 
terior edges  of  the  upper  portion  of  the  sternum.  The  interval  thus 
formed  (the  space  of  (Jruber)  contains  fat,  the  sternal  head  of  the 
sternomastoid  and  the  anterior  jugular  veins. 

Just  below  the  mastoid  process  a  superficial  layer  of  the  deep 
fascia  is  continued  over  the  parotid  gland  and  the  masseter  muscle  as 
the  parotid  and  masseteric  fascia,  and  is  attached  to  the  lower  border 
of  the  zygoma. 

From  the  deep  fascia  processes  extend  between  the  various  struc- 
tures of  the  neck.  At  the  angle  of  the  jaw  it  becomes  thickened  and 
forms  the  stylomandibular  ligament,  which  extends  from  the  tip  of  the 
styloid  process  to  the  posterior  border  of  the  angle  of  the  mandible. 
Other  thickenings  of  this  fascia  form  the  pterygospinous  ligament 
and  the  stylohyoid  ligament.  This  latter  ligament  runs  from  the  tip 
of  the  styloid  process  to  the  lesser  cornu  of  the  hyoid  bone. 

Two  main  processes  are  given  off  from  the  deep  fascia,  a  posterior 
and  an  anterior.  The  posterior  process,  or  prevertehral  fascia,  arises 
at  the  anterior  border  of  the  trapezius  muscle,  and  covers  the  numer- 
ous muscles  of  the  back  of  the  neck,  the  brachial  plexus,  the  phrenic 
and  cervical  sympathetic  nerves  and  passes  inward  behind  the  large 
vessels,  the  pharynx  and  the  esophagus  to  meet  its  fellow  of  the  other 


OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 

side.  It  is  attached  above  to  the  base  of  the  skull  and  below  to  the  first 
rib  as  far  forward  as  the  anterior  border  of  the  anterior  scalenus  muscle. 
It  also  passes  down  into  the  chest  over  the  longus  colli  muscle  and  the 
bodies  of  the  vertebra*.  It  forms  the  sheath  of  the  subclavian  and  axil- 
lary vessels  by  a  process  beginning  just  outside  of  the  anterior  scalenus 
muscle.  In  conjunction  with  the  anterior  process  it  forms  the  sheath 
of  the  carotid  artery  and  internal  jugular  vein. 

The  anterior  process,  or  pretracheal  fascia,  passes  inward  and  for- 
ward from  the  anterior  border  of  the  sternomastoid  just  in  front  of 
the  trachea,  and  envelopes  the  thyroid  gland.  It  is  attached  below  to 
the  first  rib. 

The  dee])  cervical  fascia  surrounding  the  trachea  and  the  great 
vessels  follows  these  structures  down  into  the  chest  where  it  is  con- 
tinuous with  the  fibrous  layer  of  the  pericardium.  The  prevertebral 
and  the  pretracheal  fascia*  divide  the  neck  into  three  compartments. 
The  anterior  compartment  contains  the  anterior  belly  of  the  omohyoid, 
the  sternothyroid  and  the  sternohyoid  muscles.  The  middle  contains 
the  pharynx,  esophagus,  trachea  and  the  thyroid  gland;  while  the  pos- 
terior contains  the  vertebral  column,  the  upper  vertebral  muscles,  the 
scalene  muscles,  the  levator  anguli  scapula*,  and  the  whole  musculature 
of  the  back  of  the  neck  with  the  exception  of  the  trapezius. 

The  most  important  compartment  formed  by  the  dee])  cervical 
fascia  is  the  visceral  compartment.  This  compartment  is  bounded  an- 
teriorly by  the  pretracheal  fascia,  posteriorly  by  the  pervertebral 
fascia  and  laterally  by  the  fascia  forming  the  sheath  of  the  dee])  blood 
vessels.  It  extends  from  the  base  of  the  skull  downward  into  the  pos- 
terior mediastinum.  In  front  it  runs  from  the  hyoid  bone  into  the 
anterior  part  of  the  superior  mediastinum. 

The  Sternocleidomastoid  Muscle  is  the  most  prominent  muscular 
landmark  of  the  neck.  It  forms  a  distinct  ridge  of  swelling,  running 
from  the  mastoid  process  downward  and  forward  across  the  side  of 
the  neck  to  the  region  of  the  steriioclavicular  articulation.  It  has  two 
heads,  one,  the  sternal  head,  a  narrow  tendinous  structure  which  arises 
from  the  anterior  surface  of  the  nianubriuni  of  the  sternum,  and  a  cla- 
vicular head,  broader  and  only  (tartly  tendinous,  which  arises  from  the 
upper  surface-  of  the  inner  third  of  the  clavicle.  It  is  inserted  by  a 
rather  broad  attachment  into  the  outer  surface  of  the  mastoid  process, 
and  into  the  adjoining  portion  of  the  superior  curved  line  of  the  occip- 
ital bone.  Its  anatomic  relations  are  very  important.  Its  anterior 
border,  beginning  above,  is  the  superficial  landmark  for  the  location 
of  the  facial  and  spinal  accessory  nerves  and  of  all  t  he  st  met  i  ires  which 
occupy  the  carotid  triangle,  such  as  the  juirnlar  and  adjoining  lymph 


SUKOK'AI.  ANATOMY   OF   T  1 1  K   I'HAKY.NX,  LARYNX,  AND    N  KC  K  .  *!> 

nodes  of  the  upper  (loop  cervical  chain,  the  internal  jugular  vein,  the 
carotid  arteries  and  the  various  branches  of  the  external  carotid,  and, 
it'  they  are  desired  to  be  approached  near  their  origin,  the  hypoglossal 
the  pneumogastric,  the  sympathetic,  and  the  glossopharyngeal  nerves. 
Lower  down,  its  anterior  border  is  the  landmark  for  the  common  car- 
otid and  internal  jugular  veins,  the  descendens  hypoglossi,  and  tlie  su- 
perior and  recurrent  laryngeal  nerves.  Tlie  anterioi1  part  of  the  upper 
extremity  of  the  muscle  is  covered  by  the  parotid  inland.  About  one- 
fourth  of  the  way  down  its  anterior  border,  the  sternocleidomastoid 
muscle  covers  the  posterior  belly  of  the  digastric  muscle  as  it  passes 
upward  and  backward  to  its  insertion  into  the  mastoid  process. 

The  Submaxillary  Salivary  Gland  is  situated  just  beneath  the  hori- 
zontal ramus  of  the  mandible  near  the  angle  and  is  partially  covered 
by  it.  It  occupies  a  triangular  space  which  is  bounded  externally  and 
above  by  the  inner  surface  of  the  mandible,  externally  and  below  by 
the  skin  and  fascia  as  they  pass  from  the  edge  of  the  jaw  to  the  neck, 
and  internally  by  the  mylohyoid  muscle.  The  posterior  part  of  the 
inland  also  rests  internally  on  the  hyoglosstis,  the  posterior  belly  of  the 
digastric  and  the  stylohyoid  muscles.  It  is  crossed  externally  by  the 
facial  vein,  while  the  facial  artery  passes  through  a  groove  on  its  ex 
ternal  inferior  surface.  The  posterior  end  of  the  gland  which  is  really 
the  most  bulky  portion  very  often  reaches  to  the  anterior  edge  of  the 
sternomastoid  muscle.  Along  its  upper  border  just  beneath  the  lower 
edge  of  the  jaw,  the  submaxillary  lymph  nodes  are  sometimes  very 
closely  associated  with  its  capsule,  so  that  in  malignant  disease  with 
metastasis  to  the  submaxillary  lymph  nodes  it  is  probably  best  to  re- 
move the  salivary  gland,  as  well  as  the  lymph  nodes  in  order  to  be  sure 
that  tlie  disease  is  eradicated.  The  submaxillary  or  Wharton's  due*: 
leaves  the  gland  from  the  anterior  end  and  is  often  accompanied  by  a 
tongue-like  prolongation  of  the  glandular  tissue. 

The  Digastric  Muscle  consists  of  two  bellies,  a  posterior  and  an 
anterior.  The  posterior  belly  arises  from  the  digastric  groove  on  the 
internal  surface  of  the  mastoid  process.  It  runs  forward  and  down- 
ward, passing  through  the  stylohyoid  muscle,  where  it  becomes  ten- 
dinous. This  tendon  is  attached  to  the  upper  surface  of  the  hyoid  bone 
by  a  pulley-like  band  from  the  cervical  fascia.  The  tendon  passes  on 
through  this  pulley  and  becoming  lleshy,  forms  tin-  anterior  belly,  which 
is  inserted  into  the  lower  border  of  the  lower  jaw  close  to  the  symphysis. 

The  Stylohyoid  Muscle  arises  from  the  base  of  the  styloid  process 
of  the  temporal  bone,  and  after  enclosing  the  digastric,  is  inserted  into 
the  body  of  the  hyoid  bone.  Its  course  is  almost  parallel  with  that  of 
the  digastric.  These  two  muscles  form  the  posterior  inferior  boundary 


90 


OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 


of  the  submaxillary  triangle,  and  are  important  landmarks  for  the 
deeper  structures.  Superficial  to  them  will  be  found  the  anterior 
division  of  the  temporomaxillary  vein,  the  facial  vein,  and  their  com- 
mon trunk  as  it  passes  downward  and  inward  to  join  the  internal  jug- 
ular. 

Facial  Nerve. — In  this  position,  it  is  well  to  bear  in  mind  the  rela- 
tion of  the  supramandibular  and  inframandibular  branches  of  the  facial 


,10 

11 
1-2 


FiK. 


Dissection  of  the  pes  anserinus  of  the  facial  nerve.  The  dotted  line 
represents  the  normal  outline  of  the  parotid  gland. 

1,  Parotid  gland;  2,  Temporofacial  division;  '.",,  Cervicofacial  division; 
4,  Stylohyoid  and  digastric  hranches;  5,  Lymph  nodes  of  the  upper  deep 
cervical  group;  6,  Temporal  branch;  7,  Malar  branch;  8,  Infraorbital 
branch;  9,  Branches  to  parotid  gland;  10,  Huccal  branch;  11,  Supramandib- 
ular branch;  12,  Facial  artery;  !.'{,  Inframandibular  branch. 

nerve.  These  nerves  generally  come  from  a  common  stem,  the  cervieo- 
facial.  The  inframandibular  branch  passes  down  from  beneath  the  in- 
ferior edge  of  the  parotid  gland  to  supply  the  platysma  myoides,  and  to 
form  a  communication  with  the  superficial  cervical  nerve  of  the  cervical 
plexus.  From  its  superficial  position,  this  nerve  is  almost  bound  to 


SURGICAL  ANATOMY  OK  THE  IM1AKYXX,  LAKYNX,  AND   XKCK. 

be  cut  in  the  operations  on  this  region.  Fortunately,  the  results  are  of 
little  consequence.  The  supramandibular  branch,  emerging  from  be- 
neath the  parotid  gland,  slightly  in  front  of  the  inframandibular 
branch,  sweeps  forward  and  downward  to  the  inferior  edge  of  the 
mandible,  follows  this  to  the  anterior  border  of  the  masseter  muscle, 
and  turning  slightly  upward  supplies  the  depressor  anguli  oris,  the 
depressor  labii  inferioris,  and  the  orbicularis  oris.  The  position  of 


1- 

2— 
3~ 

4- 

5 

6- 

7  ' 

8  -- 
9--- 


Fig.  70. 
Deep  dissection  of  the  carotid  triangle. 

1,  Parotid  gland;  2,  Inframandibular  branch  of  facial  nerve;  3,  Sterno- 
mastoid  muscle  reflected;  4,  Spinal  accessory  nerve;  5,  Hypoglossal  nerve: 
6,  Internal  carotid  artery;  7,  External  carotid  artery;  8,  Descendens  hypo- 
glossi;  9,  Common  carotid  artery;  10,  Internal  jugular  vein;  11,  Supraniandib- 
ular branch  of  facial  nerve;  12,  Posterior  belly  of  digastric  muscle;  13,  Sty- 
lohyoid  muscle;  14,  Facial  vein;  15,  Facial  artery;  16,  Anterior  division  of 
temporomaxillary  vein;  17,  Submaxillary  salivary  gland;  18.  Anterior  belly 
of  digastric  muscle;  19,  Lingual  vein;  20,  Temporofacial  vein;  21,  Internal 
laryngeal  nerve;  22,  Superior  thyroid  artery. 

this  branch  of  the  nerve  is  somewhat  variable,  and  occasionally,  just 
after  it  emerges  from  the  parotid  gland,  its  course  is  so  far  down  as  to 
make  it  very  open  to  injury  in  removing  the  lymph  nodes  at  the  angle 
of  the  jaw.  Cutting  of  this  nerve  is  deplorable  as  it  paralyzes  one-half 
of  the  lower  lip. 


OPERATIVE    SUKCERY    OF    THE    NOSE,    THROAT,,    AND    EAR. 

Internal  Jugular  Vein. — At  about  this  depth  it  is  important  to  re- 
member the  position  and  relation  of  the  large  veins  of  the  neck.  The 
internal  jugular  vein  which  is~a  continuation  of  the  lateral  sinns,  begins 
above  by  a  dilation  called  the  bulb  which  occupies  the  posterior  com- 
partment of  the  jugular  foramen.  It  runs  obliquely  downward  and 
forward,  terminating  behind  the  clavicle  near  the  sternum  where  it 
unites  with  the  subclavian  vein  to  form  the  innominate.  At  first  it  is 
behind  the  internal  carotid  artery,  but  gradually  passes  around  as  it 
descends  until  finally  it  is  on  the  outer  side  of  the  carotid  artery.  In  the 
lower  part  of  the  neck  it  sometimes  overlaps  it  in  front.  The  right 
vein  is  not  very  closely  associated  with  the  artery  at  the  base  of  the 
neck,  whilst  the  left  vein  is  almost  in  front  of  the  carotid  artery  on 
that  side.  An  imporant  tributary  to  this  vein  is  the  common  facial 
vein.  This  latter  vein  is  formed  by  the  union  of  the  facial  vein  and 
the  anterior  division  of  the  temporomaxillary  vein.  The  common 
facial  vein  crosses  over  the  external  carotid  artery  generally  a  little 
below  the  posterior  belly  of  the  digastric  muscle  and  frequently  has 
to  be  Heated  and  cut  to  expose  the  external  carotid  near  its  base. 
Sometimes  the  common  facial  vein  gives  off  at  the  anterior  edge  of 
the  sternomastoid  a  branch  which  may  be  quite  large  and  which  runs 
along  the  anterior  border  of  the  sternomastoid  to  the  suprasternal 
fossa  where  it  joins  the  anterior  jugular  vein.  The  internal  jugular 
vein  occupies  the  connective  tissue  sheath  in  common  with  the  carotid 
arteries  and  the  pneumogastric  nerve. 

The  Hypoglossal  Nerve  leaves  the  skull  through  the  anterior  con- 
dyloid  foramen.  It  arches  downward  and  forward  passing  to  the  outer 
side  of  both  the  internal  and  external  carotid  arteries  and  internal  to 
the  posterior  belly  of  the  digastric  and  the  stylohyoid  muscles.  As  it 
crosses  the  internal  carotid  artery  it  passes  below  and  around  the  oc- 
cipital artery.  In  its  course  this  nerve  communicates  with  the  pharyn- 
U'eal  branch  of  the  vagus,  and  sends  a  small  branch  k>  the  thyrohyoid 
muscle.  It  passes  forward  beneath  the  stylohyoid  muscle  and  external 
to  the  hvoglossus  muscle  just  above  the  hyoid  hone.  In  this  position 
it  is  an  important  landmark  for  an  approach  to  the  lingual  artery.  'I"1  he 
lingual  branches  of  this  nerve  are  distributed  to  the  liyou'lossus.  the 
geniohyoid  and  the  geniohyoglossus  muscles  and  practically  to  all  the 
intrinsic  muscles  of  the  tongue.  'The  descendens  hypoglossi,  a  rather 
laru'e  branch  of  the  hypoglossal,  descends  along  the  external  surface 
of  the  carotid  .-heath,  though  sometimes  it  occupies  the  interior  of  the 
sheath  and  forms  with  a  branch  from  the  second  and  third  cervical 
nerves  the  aiisa  hypoglossi.  Branches  from  this  plexus  run  to  the  omo- 
hyoid.  the  sternothyroid  and  the  stcrnohyoid,  but  it  is  probable  that  the 


SURGICAL  ANATOMY  OK  TIIK  IMIAIiYX.X,  LAHVNX,  AND   NKCK. 

iniiervation  of  these  muscles  comes  through  the  cervical  nerves  ami  not 
1  lirough  the  liypoglossal. 

The  Common  Carotid  Artery  arises  on  the  right  side  of  the  neck 
from  the  innominate  artery,  and  on  the  left  side  from  the  arch  of  the 
aorta.  In  the  neck,  however,  the  two  arteries  have  practically  the  same 
relations.  It  is  important  to  remember,  however,  that  the  thoracic 
duct  passes  immediately  behind  the  left  carotid  artery  just  before 
archill,**1  downward  to  enter  the  innominate  vein,  and  the  recurrent  lar- 
yngeal  nerve  has  already  passed  to  the  inner  side  of  the  artery  before 
the  artery  enters  the  neck  proper.  On  the  right  side  the  recurrent  laryn- 
geal  nerve  lies  behind  the  carotid  artery  in  the  lower  part  of  the  neck. 
At  about  the  level  of  the  tirst  ring  of  the  trachea  the  inferior  thyroid 
artery,  a  branch  of  the  thyroid  axis,  passes  immediately  behind  the 
common  carotid.  The  sternomastoid  branch  of  the  superior  thyroid 
artery  crosses  over  the  common  carotid  along  the  anterior  edge  of  the 
omohyoid  at  about  the  level  of  the  sixtli  cervical  vertebra.  A  line  for 
the  common  cartoid  is  from  the  upper  part  of  the  sternoclavicular  ar- 
ticulation to  a  point  midway  between  the  angle  of  the  jaw  and  the  tip 
of  the  mastoid  process.  The  point  of  bifurcation  into  the  two  termi- 
nal branches,  the  external  and  internal  carotid  arteries,  is  usually  on 
a  level  with  the  upper  border  of  the  thyroid  cartilage.  It  is,  however, 
not  uncommon  for  the  external  carotid  to  be  given  off  considerably 
higher  up,  and  this  anomalous  condition  sometimes  makes  it  difficult 
to  quickly  reach  the  external  carotid  for  ligation. 

The  Omohyoid  Muscle  which  crosses  the  common  carotid  externally 
consists  of  two  bellies,  the  anterior  and  the  posterior.  It  arises  from 
the  upper  border  of  the  scapula  and  the  snprascapular  ligament  and, 
passing  forward  and  slightly  upward,  becomes  tendinous  beneath  the 
sternomastoid  muscle.  This  part  of  the  muscle  is  called  the  posterior 
belly.  The  anterior  belly  begins  from  this  intermediary  tendon  and 
passes  obliquely  upward  and  forward  to  be  inserted  into  the  outer  edge 
of  the  lower  border  of  the  body  of  the  hyoid  bone.  The  intermediary 
tendon  is  held  in  place  to  the  first  rib  by  a  process  of  the  dee])  cervical 
fascia.  The  anterior  belly  of  the  muscle  forms  the  upper  boundary  of 
the  inferior  carotid  triangle  and  crosses  the  common  carotid  artery  at 
about  the  level  of  the  cricoid  cartilage. 

The  External  Carotid  Artery  is  usually  about  two  and  a  half  inches 
long  and  supplies  blood  to  the  upper  part  of  the  neck  and  nearly  the 
whole  of  the  head  and  face,  outside  of  the  cranium.  Its  course  is  gen- 
erally at  first  slightly  forward,  then  backward,  upward  and  inward,  be- 
hind the  posterior  belly  of  the  digastric  and  the  stylohyoid  muscles  to 
the  under  surface  of  the  parotid  gland.  It  terminates  near  the  upper 


94  OPERATIVE    SUHOERY    OF    THE    XOSE,    THROAT,    AND    EAR. 

part  of  the  gland,  generally  beneath  it  but  sometimes  in  its  substance 
by  dividing  into  the  internal  maxillary  and  the  superficial  temporal 
arteries. 

The  Superior  Thyroid  Artery,  the  first  branch  of  the  external 
carotid,  arises  from  the  front  of  the  carotid  just  below  the  tip  of 
the  great  cornu  of  the  liyoid  bone.  The  artery  runs  at  first  forward, 
but  soon  turns  downward,  sending1  brandies  to  the  larynx,  sternomas- 
toid  muscle  and  the  thyroid  gland.  In  the  beginning1  of  its  course  it 
lies  on  the  inferior  constrictor  muscle,  and  is  in  very  close  relation 
with  the  external  laryngeal  branch  of  the  superior  laryngeal  nerve. 
For  a  short  distance  after  leaving1  the  cover  of  the  sternomastoid  the 
artery  is  directly  under  the  deep  cervical  fascia,  but  lower  down  it  is 
covered  by  the  omohyoid,  sternohyoid  and  sternothyroid  muscles  and 
is  generally  overlapped  by  its  accompanying  vein. 

The  Ascending  Pharyngeal  Artery,  the  second  branch,  arises  from 
the  inner  surface1  of  the  external  carotid,  almost  opposite  the  superior 
thyroid  and  runs  upwards  on  the  constrictor  muscles  of  the  pharynx 
to  supply  the  wall  of  the  pharynx  and  the  soft  palate.  A  palatine  branch 
from  this  artery  is  not  a  constant  structure,  but  when  present  takes 
the  place  of  the  ascending  palatine  branch  of  the  facial,  and  supplies 
the  upper  part  of  the  tonsil. 

The  Lingual  Artery,  the  third  branch,  springs  from  the  front  of 
the  external  carotid  just  above  the  superior  thyroid  and  about  opposite 
the  tip  of  the  great  cornu  of  the  hyoid  bone.  The  artery  forms  a  loop 
upwards  in  the  first  part  of  its  course,  and  here,  except  that  it  is  crossed 
superficially  by  the  hypoglossal  nerve,  it  is  covered  only  by  the  skin, 
fascia  and  platysma.  Reaching  the  posterior  border  of  the  hyoglos- 
sus  muscle  it  passes  beneath  this  structure  just  above  the  great  cornu 
of  the  hyoid  hone.  It  terminates  as  the  rauine  artery,  and  is  the  chief 
blood  supply  to  the  tongue. 

The  Facial  Artery,  the  fourth  branch,  arises  from  the  carotid  im- 
mediately above  the  lingual,  but  passes  upward  to  the  inner  side  of  the 
posterior  belly  of  the  digastric  and  runs  forward  and  downward 
through  a  special  groove  in  the  submaxillary  gland  to  the  margin  of 
the  jaw,  just  in  front  of  the  masseter  muscle.  Sometimes,  however, 
after  reaching  the  upper  border  of  the  digastric  muscle,  it  loops  up- 
wards until  it  comes  into  close  proximity  with  the  inferior  pole  of  the 
tonsil,  though  always  separated  by  the  middle  const  rictor  muscle. 
After  reaching  the  edge  of  the  jaw,  the  facial  artery  passes  just  be- 
neath the  fjiscia  and  skin  to  supply  the  various  structures  of  the  face, 
terminating  in  the  angular  artery  on  the  side  of  the  nose. 

The  Occipital  Artery,  the  fifth  branch,  arises  from  the  back  of  the 


SURGICAL  ANATOMY  OF  TIIK  1'HAKYXX,  LAKYNX,  AND  NKCK.  J)f> 

external  carotid  just  below  the  posterior  belly  of  the  digastric  and  run- 
ning upward  and  backward  under  the  posterior  belly  of  the  digastric, 
it  crosses,  first  the  internal  carotid  artery,  then  the  hypoglossal  nerve, 
the  pneumogastric  nerve,  the  internal  jugular  vein  and  lastly  the  spinal 
accessory  nerve.  The  hypoglossal  nerve  hooks  around  the  artery  just 
as  it  branches  from  the  carotid.  By  passing  between  the  transverse 
process  of  the  atlas  and  the  base  of  the  skull,  the  occipital  artery 
reaches  the  digastric  groove  of  the  niastoid  process.  In  this  part  of 
its  course  it  is  separated  from  the  vertebral  artery  by  the  rectus  capitis 
lateralis  muscle. 

The  Posterior  Auricular  Artery,  the  sixth  branch,  leaves  the  back 
of  the  external  carotid  just  above  the  digastric  muscle  and  passing 
under  the  posterior  part  of  the  parotid  gland  runs  between  the  mastoid 
process  and  external  auditory  meatus,  where  it  is  in  close  relation 
with  the  posterior  auricular  branch  of  the  facial  nerve. 

The  Internal  Maxillary  Artery,  the  seventh  branch,  one  of  the  ter- 
minal branches  of  the  external  carotid,  begins  behind  the  neck  of  the 
lower  jaw  and  passes  forward  to  supply  practically  all  of  the  internal 
structures  of  the  face.  The  first  part  of  the  artery  is  closely  associ- 
ated with  the  auriculotemporal  nerve  and  internal  maxillary  vein,  and 
it  lies  between  the  sphenomandibular  ligament  and  the  neck  of  the 
jaw.  Its  second  part,  occupying  the1  zygomatic  fossa,  may  run  either 
over  or  under  the  lower  head  of  the  external  pterygoid  muscle.  AY  hen 
it  passes  between  the  heads  of  the  external  pterygoid  muscle  it  comes 
into  close  relationship  with  the  third  division  of  the  fifth  nerve.  The 
third  part  of  the  artery  runs  between  the  lower  heads  of  the  external 
pterygoid,  thence  through  the  pterygomaxillary  fissure  into  the 
sphenomaxillary  fossa.  This  artery  gives  off  numerous  branches,  one 
of  which,  the  posterior  or  descending  palatine,  runs  downward  through 
the  posterior  palatine  canal  to  the  roof  of  the  mouth,  where  it  crosses 
forward  beneath  the  mucous  membrane  just  inside  the  alveolar  proc- 
ess. It  gives  off  small  branches  which  supply  the  soft  palate  and  anas- 
tomose with  the  ascending  palatine  and  tonsillar  branches  of  the 
facial  and  probably  with  the  ascending  pharyngeal  artery.  Another 
branch,  the  vidian,  supplies  branches  to  the  upper  part  of  the  pharynx 
and  to  the  Eustachian  tube.  Another  branch,  the  pterygopalatine  sup- 
plies the  upper  and  back  part  of  the  nose,  the  pharyngeal  vault  and 
surrounding  structures. 

The  Superficial  Temporal  Artery,  the  eighth  branch,  the  second  of 
the  terminal  branches  of  the  external  carotid,  begins  in  the  upper  part 
of  the  parotid  gland  behind  the  neck  of  the  mandibular,  and,  dividing 


JK>  OPERATIVE    SURCERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

into  an  anterior  and  posterior  branch,  supplies  the  anterior  half  of  the 
scalj). 

The  Internal  Carotid  Artery,  beginning-  at  the  level  of  the  upper 
border  of  the  thyroid  cartilage,  runs  upward  and  inward  posterior  and 
external  to  the  external  carotid.  It  passes  into  the  skull  through  the 
carotid  canal  of  the  temporal  bone.  Posterior  to  the  artery  and  slightly 
internal  are  the  rectns  capitis  anticus  major  muscle,  the  prevertebral 
fascia  and  the  sympathetic  cord.  The  internal  jugular  vein  and  vagus 


18 

Fig.   71. 

The  relation  of  the  palatal  tonsil  to  the  vessels  and  nerves  of  the  caro- 
tid   triangle.      Portion    of   the    mandible   has   been    resected   and    the   tongue 


1,  Palatal  tonsil  reflected  backward  and  upward  from  its  bed;  2,  Uvula; 
'.',,  External  carotid  artery;  4,  Palatopharyngeal  muscle;  f>,  Internal  carotid 
artery;  6,  Ascending  pharyngeal  artery;  7,  Lateral  pharyngeal  wall  drawn 
inward  and  backward;  8,  Anterior  palatal  pillar  drawn  upward:  !),  Facial 
artery;  10,  Lingual  nerve;  11,  Cut  surface  of  tongue;  12,  Glossopharyngeal 
nerve;  1M,  Hypoglossal  nerve;  14,  Lingual  artery;  in,  Styloglossus  muscle; 
I*!,  Superior  thyroid  artery;  17,  Superior  laryugeal  nerve;  18,  Common 
carotid  artery. 

nerve,  while  on  a  plain  posterior  to  the  artery,  are  generally  somewhat 
external  to  it.  The  spinal  accessory  and  glossopharyngeal  nerves  for 
a  short  distance  in  the  upper  part  of  the  neck  arc  found  behind  and 
slightly  to  the  outer  side  passing  between  it  and  the  internal  jugular 
vein.  Internally  it  is  closely  associated  with  the  wall  of  the  pharynx 


Sl'K<;iCAI,  ANATOMY   OK   TIIK   I'HAItYNX,   LARYNX,  AND    NKCK.  !>/ 

hut  separated  by  the  ascending  pharyngeal  artery,  Ili<-  pharyn.u'eal 
plexus  of  veins  and  the  superior  laryugeal  nerve.  Just  hefore  Ihe 
artery  enters  the  temporal  hone  the  levator  palati  muscle  is  found 
on  its  inner  side.  It  is  crossed  externally  hy  the  hypou'lossa! 
nerve  and  the  occipital  and  posterior  auricular  arteries,  and 
it  is  separated  from  the  external  carotid  hy  the  stylopharyngens  and 
styloglossus  muscles,  the  stylohyoid  ligament,  the  glossopharyn- 
geal  nerve,  the  pharyugeal  branch  of  the  vagus,  and  some  fine  sympa- 
thetic twigs.  rriie  digastric  and  stylohyoid  muscles  run  external  hotli 
to  it  and  to  the  external  carotid.  The  upper  part  of  the  internal  carotid 
in  the  neck  is  covered  hy  the  parotid  gland.  As  a  rule  no  tranches  arc 
given  off  from  the  internal  carotid  artery,  while  in  the  neck. 

The  Pneumogastric  or  Vagus  Nerve  occupies  the  carotid  sheath  be- 
inii'  placed  behind  and  between  first  the  internal,  then  the  common  car- 
otid artery  and  the  internal  jugular  vein.  Two  gaiiiiTia  are  found  on 
the  pneumogastric  nerve  as  it  leaves  the  skull  through  the  jugular 
foramen.  The  upper  and  smaller  one,  the  ganglion  of  the  root,  gives 
off  a  meningeal  branch  and  an  auricular  (Arnold's  nerve)  branch. 
The  latter  generally  communicates  with  the  tympanic  branch  of  the 
glossopharyngeal,  also  with  the  facial  nerve.  The  lower  ganglion  of 
the  trunk  gives  off  the  pliaryngeal  branch  and  the  superior  laryngeal 
nerve1.  The  pliaryngeal  branch  which  really  derives  its  fibres  from  the 
spinal  accessory  nerve,  runs  between  the  internal  and  external  carotid 
arteries  and  helps  in  the  formation  of  the  pharyngeal  plexus. 

The  Superior  Laryngeal  Nerve  runs  downward  and  inward  behind 
the  external  and  internal  carotid  arteries  to  the  thyroid  cartilage.  In 
its  course  it  divides  into  the  internal  and  external  laryngeal  nerves. 
The  internal  laryngeal  nerve  gains  access  to  the  larynx  by  running  be- 
tween the  middle  and  inferior  constrictor  muscle  of  the  pharynx  and 
through  the  thyrohyoid  membrane.  The  external  laryngeal  nerve 
passes  downward  upon  the  inferior  constrictor  muscle  ending  in  the 
cricothyroid  in  the  lower  part  of  the  neck. 

The  Recurrent  or  Inferior  Laryngeal  Nerve  is  a  branch  of  the  vagus. 
On  the  right  side  of  the  neck  it  leaves  the  vagus  as  it  passes  over  the 
subclavian  artery.  It  then  runs  upward  behind  the  subclaviau,  the 
common  carotid  and  the  inferior  thyroid  arteries,  and  behind  the  thy- 
roid body.  It  enters  the  larynx  by  passing  beneath  the  lower  border  of 
the  inferior  constrictor  muscle.  The  left  recurrent  laryngeal  nerve 
leaves  the  vagus  as  it  crosses  the  aortic  arch.  Passing  around 
and  behind  the  arch  it  runs  upward  in  the  interval  between  the  trachea 
and  esophagus.  In  the  neck  its  course  is  similar  to  that  on  the  right 
side. 


98  OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AXD    EAR. 

The  Spinal  Accessory  Nerve  divides  in  the  jugular  foramen,  the 
accessory  portion  of  the  nerve  joining  the  vagus.  The  spinal  portion 
of  the  nerve  then  runs  downward  into  the  neck,  occupying  at  first  the 
interval  between  the  external  carotid  artery  and  the  internal  jugular 
vein.  It  runs  downward,  outward,  and  then  crosses  obliquely  back- 
ward over  the  vein  to  reach  the  internal  surface  of  the  sternomastoid 
muscle.  It  then  pierces  this  muscle,  sending  fibres  to  it,  and  enters 
the  posterior  triangle  of  the  neck  near  the  exit  of  the  cervical  plexus. 
Crossing  the  posterior  triangle  it  supplies  the  trapezius  muscle  enter- 
ing on  its  inner  surface. 

The  Glossopharyngeal  Nerve  leaves  the  skull  through  the  jugular 
foramen  and  arching  downward  and  forward  passes  between  the  in- 
ternal carotid  artery  and  the  internal  jugular  vein,  and  below  the  ex- 
ternal carotid.  It  passes  around  the  outside  of  the  stylopharyngeus 
muscle  and  the  stylohyoid  ligament  and  below  the  hyoglossus  muscle, 
terminating  in  the  tongue.  It  innervates  the  stylopharyngeus  muscle 
and  sends  important  branches  to  the  pharyngeal  plexus.  It  also  sends 
a  few  direct  fibres  to  the  mucous  membrane  of  the  pharynx  and  another 
branch  to  form  the  tonsillar  plexus  which  supplies  the  mucous  mem- 
brane covering  the  tonsil  and  the  immediate  surrounding  region. 

The  Pharyngeal  Plexus  of  nerves  is  made  up  of  branches  from  the 
glossopharyngeal  and  the  pneumogastric  nerves  and  the  superior  cer- 
vical ganglion  of  the  sympathetic. 


CHAPTER    III. 
THE  SURGICAL  ANATOMY  OF  THE  EAR. 

I>Y    (iKORiiK    I"].    Sll.\.MMAf(;||.    M.    I). 

Introduction. 

Xowhere  is  surgery  more  dependent  on  a  knowledge  of  anatomic 
details  than  in  the  operations  upon  the  ear.  In  the  temporal  hone  al- 
located a  number  of  important  anatomic  structures  a  slight  injury 
of  which  may  be  followed  by  serious  results.  The  fact  that  these 
structures  encroach  on  the  field  of  operation  which  lies  deep  in  the 
temporal  bone  makes  the  danger  from  injury  much  greater  than  when 
the  operating  is  done  in  soft  structures. 

The  perfecting  of  aural  surgery  is  the  direct  result  of  the  modern 
tendency  to  specialization  which  has  made  it  possible  for  the  otologist 
to  master  the  complicated  anatomy  of  this  region.  The  iirst  problem 
for  the  surgeon  who  would  undertake  the  operations  on  the  ear  is  to 
master  the  details  of  the  anatomy  of  this  region.  This  cannot  he  ac- 
quired from  text-books  nor  is  this  knowledge  readily  gained  by 
attempts  to  do  these  operations  on  the  cadaver.  A  thorough  grasp  of 
the  complicated  anatomy  of  the  temporal  bone  is  best  acquired  by  a 
study  of  preparations  made  especially  to  show  this  or  that  relation. 
The  knowledge  comes  through  the  actual  making  and  handling  of  such 
preparations.  The  most  that  can  be  hoped  from  a  chapter  on  the  sur- 
gical anatomy  of  the  ear  is  to  point  out  the  various  relations  which 
must  be  kept  in  mind  when  undertaking  the  surgery  of  this  region  and 
to  emphasize  these  relations  by  drawings  from  actual  preparations. 
The  study  of  such  a  chapter  can  in  no  sense  serve  as  an  adequate  sub- 
stitute for  the  actual  handling  of  anatomic  preparations,  which  after 
all  is  the  only  way  of  acquiring  real  anatomic  knowledge.  It  is  hoped 
that  this  chapter  may  serve  to  call  the  attention  of  the  beginner  to  the 
more  important  surgical  relations  of  the  temporal  bone  so  that  with 
this  as  a  guide  he  may  work  out  for  himself  these  relations  from  prep- 
arations of  his  own. 

The  Development  of  the  Temporal  Bone. 

The  temporal  bone  is  formed  from  three  parts,  the  pars  petrosa,  the 
pars  squamosa  and  the  pars  tympanica,  which  in  the  new-born  are 

(tnn 


100  OPERATIVE    STKOEUY    ()!•"    THE    NOSE,    THROAT,    AXD    EAR. 

sharply  separated  by  well  marked  sutures.  Of  these  the  petrous  is  the 
most  important  as  it  contains  the  labyrinth  and  it  is  from  the  petrous 
bone  that  the  mastoid  process  develops.  The  tympanic  bone  in  the 
newborn  is  but  a  shallow  curved  rim  containing  a  groove,  the  sulcus 
tympanicus,  for  the  attachment  of  the  membrana  tympani.  The  rim  is 
incomplete  at  the  upper  pole,  the  cleft  forming  the  incisura  tympanica 
in  which  the  membrane  of  Shrapnell  is  attached.  The  squamous  bone 
in  the  new  born  forms  the  outer  covering1  for  the  recessus  epitympa- 
nicus  (the  attic  and  aditus)  as  well  as  the  outer  covering  for  the  antrum 
tympanicum.  The  roof  of  these  chambers,  the  teamen  tympani  et 
antri,  is  formed  in  part  from  the  squamous  bone  and  in  part  from  the 
petrous.  The  suture  passing  directly  through  the  tollmen  is  quite 
patulent  in  the  new-born.  This  explains  the  ready  occurrence  in  the 
young'  of  meningeal  symptoms  in  cases  of  acute  suppuration  of  the 
middle  ear. 

The  outer  surface  of  the  temporal  bone  in  the  new  born  presents 
an  appearance  quite  unlike  that  seen  in  the  adult.  The  most  con- 
spicuous difference  is  the  complete  absence  of  an  osseous  external 
meatus.  The  membranous  meatus  is  connected  to  the  shallow  rim  ot 
bone,  the  pars  tympanica,  in  which  the  membrana  tympani  is  attached. 
This  close  relation  between  the  membrana  tympani  and  the  mem- 
branous external  meatus  accounts  for  the  occurrence  of  pain  in  a 
young  child  whenever  in  cases  of  acute  otitis  media  the  auricle  is  ma- 
nipulated. In  older  children  this  symptom  disappears  because  the 
cartilage  of  the  meatus  is  separated  by  a  well  developed  bony  meatus 
from  the  area  of  infiltration  about  the  attachment  of  the  membrana 
tympani.  Another  peculiarity  in  the  new-born  is  the  complete  absence 
of  a  mastoid  process.  Thai  part  of  1he  pelrous  bone  from  which  Ihe 
proccssus  masloideiis  develops  presents  a  flat  surface  with  scarcely  a 
suggestion  of  a  prominence  from  which  the  process  develops.  A  con- 
spicuous suture  beginning  opposite  the  middle  of  the  posterior  wall  of 
the  tympanum  and  coursing  upward  and  backward  to  a  notch  on  the 
posterior  margin  of  the  temporal  bone  marks  the  union  between  the 
petrous  and  sqiiamous  bones.  (Fig.  7'2.)  This  suture,  the  petrosqiia- 
mosal,  opens  directly  into  the  antrum  tympanicum  and  often  persists 
in  the  adult  as  a  depression  into  which  the  periosteum  penetrates.  The 
persistence  of  the  petrosquamosal  suture  in  children  has  an  important 
practical  bearing  on  the  course  of  antrum  infection  at  this  age  as  it 
permits  of  the  rapid  development  of  a  suhperiosteal  abscess.  It  ex- 
plains also  why  a  simple  Wild's  incision  in  an  infant  is  so  much  more 
effective  than  in  the  adult.  A  Wild's  incision  in  an  infant  for  the 
relief  of  a  subperiosteal  abscess  formed  by  an  extension  from  the 


TIIK  srmncAL  ANATOMY  OF  THK  KAI;. 


101 


antrnm  through  the  petrosquamosal  suture  amounts  often  lo  the  same 
as  a  Schwartze  operation  in  the  adult  as  it  ^ives  a  free  opening  into 
the  antrnni,  the  only  pneumatic  space  developed  at  this  a.u'e. 

On  the  outer  surface  of  the  temporal  hone,  just  hack  of  the  pars 
tympanica,  at  about  the  junction  of  the  middle  with  the  lower  thirds  of 
the  posterior  wall  of  the  tympanic  cavity,  is  a  round  opening  for  tin- 
exit  of  the  facial  nerve.  It  is  important  that  this  position  of  the  stylo- 
mastoid  opening  in  the  infant  he  kept  in  mind  when  making  the  incision 


Fig.  72. 


Fis 


Fig.  72.  Temporal  bone  from  ne\v-born,  showing  distinctly  the  three 
parts  which  go  to  make  up  this  bone:  the  pars  squamosa,  pars  tympanica, 
pars  petrosa.  Note  the  absence  of  bony  external  meatus  and  the  absence 
of  a  mastoid  process.  The  opening  of  the  facial  canal  is  on  the  exposed 
outer  surface  of  the  temporal  bone.  (Dr.  G.  W.  Boot's  preparation.  I 

Fig.  7;'..  Temporal  bone  from  child  one  year  old.  showing  the  per- 
sistence of  the  petrosquamosal  suture,  also  the  beginning  of  a  mastoid 
process  which  is  still  to  small  to  cover  the  opening  of  the  facial  canal. 
The  bony  external  auditory  canal  is  beginning  to  form.  The  lower  ante- 
rior part  is  still  entirely  wanting.  ( Ur.  G.  AY.  Boot's  preparation.) 


for  the  relief  of  a  subperiosteal  abscess,  for  this  incision  mi.u'ht   sever 
the  facial  nerve. 

In  the  development  of  the  temporal  bone  after  birth  the  two  con- 
spicuous changes  brought  about  are  the  formation  of  a  mastoid  proc- 
ess and  of  a  bony  external  meatus.  The  processus  mastoideus  develops 
largely  from  the  petrous  bone.  It  is  first  recognized  as  a  small  tubercle 
at  about  the  ai>'e  of  one  year.  (Fii*1.  "•'>.)  Its  development  takes  place 
in  two  directions,  outward,  that  is  external  to  the  cavity  of  the  tym- 
panum, and  downward  below  the  cavity  of  the  tympanum.  It  is  the 
development  of  the  processus  mastoideus  that  causes  the  stylomas- 


111!1  OPKRATIYK    SUHCKHY    OF    THE    XOSE,    THROAT,    AND    EAK. 

toid  foramen  to  recede  from  the  surface  of  the  temporal  bone  until  in 
the  adult  it  lies  fully  iT)  mm.  from  the  outer  surface  of  the  mastoid.  At 
the  age  of  three  years  the  mastoid  has  already  assumed  the  shape 
found  in  the  adult  and  the  digastric  groove  is  easily  recognized.  (Fig. 
74.)  The  pet  rosquamosal  suture  has  usually  been  obliterated  with  only 
occasionally  a  depression  marking  its  site.  The  external  bony  cover- 
ing of  the  antrum  is  still  usually  quite  porous. 

The  development  externally  of  the  processus  mastoideus  is  shared 
by  both  the  squamous  and  the  tympanic  bones.  All  three  enter  into 
the  formation  of  the  bony  external  nieatus.  In  its  development  the 
tympanic  bone  forms  a  trough  with  an  opening  above  the  posterior. 
This  trough  in  the  adult  forms  the  anterior,  the  lower,  and  part  of  the 
posterior  bony  nieatus  auditorius  externus.  The  upper  wall  of  the  bony 
nieatus  is  formed  by  a  horizontal  plate  from  the  squamous  bone.  The 
upper  posterior  margin  of  the  external  meatus  is  formed  by  the  pro- 
cessus mastoideus  and  is  developed  in  part  from  the  petrous  and  in 
part  from  the  squamous  bones.  It  is  this  upper  posterior  part  of  the 
external  bony  nieatus  that  is  occupied  frequently  in  the  adult  by  pneu- 
matic spaces,  mastoid  cells. 

Meatus  Auditorius  Externus. 

In  the  new-born,  as  already  pointed  out,  the  external  auditory 
nieatus  consists  only  of  the  cartilaginous  membranous  portion,  there 
being  no  bony  meatus.  In  the  adult  this  cartilaginous  portion  forms 
scarcely  the  outer  third  of  the  canal.  In  the  development  of  the  bony 
canal  the  part  formed  by  the  squamous  and  petrous  bones  pushes  out 
beyond  that  formed  from  the  tympanic  bone,  so  that  the  anterior  lower 
wall  of  the  bony  meatus  is  shorter  than  the  upper  and  posterior  wall. 
This  deficiency  is  pieced  out  by  an  extension  from  the  cartilage  form- 
in  ^  the  auricle.  In  this  cartilage  which  forms  the  outer  part  of  the 
anterior  lower  wall  of  the  external  meatus  are  several  clefts  called  the 
inc'isiinc  Satitorini  which  relieve  the  rigidity  of  this  part  of  the  canal 
and  permit  greater  mobility  of  the  auricle.  Through  these  clefts  in 
the  cartilage  a  parotid  abscess  occasionally  discharges  into  the  ex- 
ternal meatus  and  through  them  a  furuncle  in  the  meatus  may  dis- 
charge into  the  region  of  the  parotid. 

The  anterior  lower  wall  of  the  bony  meatus  is  formed  by  a  thin 
plate  of  bone  which  x-parates  the  meatus  from  the  glenoid  fossa.  A 
severe  blow  on  the  chin  may  fracture  this  bone  and  drive  the  head  of 
1h(1  mandible  into  the  external  nieatus.  'The  floor  of  the  external 
nieatus  make>  a  decided  curve  downward  at  its  inner  third  fori 


THK  SUK<;i('AL  AX  ATOMY   ()!•'   T  1 1  K    K.M! 


in:; 


Temporal  bone  from  child  three  years  old,  showing  the  mastoid  proc- 
ess, the  bony  external  auditory  meatus,  and  obliteration  of  the  petrosquu- 
mosal  suture.  (Dr.  G.  W.  Boot's  preparation.) 


Temporal  bone  from  child  ten  years  old.  The  adult  characters  of  the 
temporal  bone  are  developed.  Persistence  of  depression  over  the  niastoid 
showing  the  line  of  the  petrosquamosal  suture.  (Dr.  G.  \V.  Boot's  prepa- 
ration.) 


1(14 


OPKRATIVK    STKCKUV    OF    TIIK    XOSK,    THROAT,    AND    EAR. 


the  snlcus  of  the  external  ineatus.     (  Fi.u1.   <(>.)    The  narrowest  part  of 
the  external  ineatus  is  at  the  entrance  of  this  sulciis.     The  sulcus  itself 


Fig-.   Ttj. 

Frontal  section  through  the  adult  temporal  bone:  the  anterior  part 
viewed  from  behind.  Section  passes  through  external  meatus,  cavum  tym- 
pani.  and  labyrinth. 

is  at  times  so  deep  that  insects  and  small   foreign   bodies  lod.u'in.u1  in  it 
may  lie  completely  out  of  the  line  of  direct  ins],   ction. 

The  upper  posterior  wall  of  the  external  meatus  is  formed  from 
the  mastoid   process  and  this  is  the  only  part   of  the  meatus  Avail  en- 


ST>iD    CFLl 


Aduli    temporal    hour   showing   the   position    of   the   anlriini    tympanicnin 
and    masioid    ci-lls   along    the    upper    posterior    wall    of   the    external    canal. 

eroached   on    I iy   ma.-loid   cells.      Tlioe  cells   may   he    found   external   to 
the  suprameatal  spine  (  l-'iv.'.  77)  which  is  located  often  somewhat  \vi 


TITK  SUKCK'AL  ANATOMY  OK  THK  KAR. 


105 


the  outer  margin  of  the  meatus.  The  ant  rum  tyinpanicuin  lies  above 
the  upper  posterior  wall  of  Hie  meatus  just  external  to  Ilie  membrana 
tympaui.  (Fig.  77,  7S,  7!'.)  lu  cases  of  acute  iuasloi<l  disease  when  the 


Fig.  78. 

Horizontal  section  through  the  temporal  bone1  viewed  from  above.  Sec- 
tion through  the  external  canal,  cavuni  tympani,  labyrinth  and  internal 
ineatus. 


temporal  bone  is  being  involved,  a  ])eriostitis  over  this  portion  of  the 
canal  frequently  results  in  a  bulging  or  sinking  of  this  part  of  the  pos- 


Fig.  79. 

Section  through  mastoid  process  and  external  canal,  showing  pneumatic 
type  of  mastoid  with  the  larger  colls  on  the  poriphora.  also  the  position  of 
the  antrum  above  and  posterior  to  the  external  canal. 

terior  wall.  A  mastoid  abscess  frequently  discharges  into  the  external 
canal  at  this  point.  In  cases  of  chronic  suppuration  with  cholesteatoma 
formation  in  the  antrum  the  cholesteatoma  frequently  breaks  through 


KM) 


Ol'KKATIVK    SUKCKKY    OF    TJ1E    XO.SE,    THROAT,    AXD    EAR. 


into  the  external  meatus  at  this  point.  On  the  other  hand  it  should  be 
remembered  that  a  furuncle  located  along  the  posterior  wall  of  the 
meatus  may  be  confused  with  a  mastoid  abscess,  since  in  addition  to 
producing1  a  bulging  of  this  wall  of  the  canal  it  is  often  associated  with 
an  infiltration  and  edema  over  the  mastoid  process  with  displacement 
forward  of  the  auricle,  such  as  a  mastoid  abscess  produces.  The  rela- 
tion of  the  facial  canal  to  the  upper  and  posterior  walls  of  the  external 
meatus  is  of  great  surgical  importance  especially  in  doing  the  radical 
mastoid  operation.  The  inner  rim  of  the  upper  wall  of  the  external 
nieatus  lies  directly  over  the  facial  canal  from  the  point  where  the 
nerve  enters  the  tympanum  in  front  of  the  oval  window  until  it  begins 
to  curve  downward  toward  the  stylomastoid  opening.  (Figs.  7(i  and 


Section    through    temporal    bone,    showing    the    relation     of     the     facial 
canal   to   the   fenestra  vost.ibuli   and   of  the   horizontal   canal   to   the  antrum. 

M). )  In  this  part  of  its  course  the  facial  nerve  is  covered  by  an  ex- 
tremely thin  shell  of  bone  in  which  dehiscence  frequently  occurs.  From 
the  point  where  t  he  facial  canal  turns  downward  until  it  emerges  from 
the  stylomastoid  foramen  it  lies  in  the  hone  which  forms  the  posterior 
wall  of  the  bony  meatus.  At  the  point  where  this  canal  enters  tho 
posterior  wall  of  the  bony  nieatus  just  posterior  to  the  oval  win- 
dow it  lies  on  a  level  with  the  inner  wall  of  the  tympanum.  As  it 
passes  downward  it  lies  out  further  and  further  along  the  external 
meatus  so  that  at  the  level  of  the  floor  of  the  tympanum  the  canal  lies 
several  millimeters  external  to  the  inner  wall  of  the  tympanum.  (Fig. 
s'i.)  Again  the  relation  of  the  facial  canal  to  the  external  meatus  is 
such  that  where  it  enters  the  posterior  wall  of  the  nieatus  near  the  up- 
per part  of  the  tympanum  it  lies  close  to  the  meatus  wall  but  as  the 


TIIK  SrUCICAL  ANATO.MV   OF   THK    KAII. 


107 


canal  passes  downward  it  recedes  further  and  further  from  the  meatus 
until  at  the  level  of  the  floor  of  the  tympanum  it  lies  several  millimeters 
posterior  to  the  external  meatiis.  (  Kiii's.  SO  and  Si.)  These  relations 


Fig.  81. 
Section    through    temporal   bone,    exposing   the    facial   canal. 

of  the  facial  canal  to  the  posterior  wall  of  the  external  ineatus  make  it 
necessary,  when  performing  the  radical    mastoid    operation,    to    leave- 


Fig.  8'2. 

Adult    temporal    bone,    showing    anatomic     relations     after     a     complete 
tympanomastoid    exenteration. 

standing  a  part  of  the  posterior  wall  of  the  canal.  (  Fii>\  82.)  On  the 
other  hand  it  is  possible  to  remove  the  ledge  of  hone  lying  in  front  of 
the  facial  canal  which  separates  the  canal  from  the  meatus. 


108 


OPERATIVE    SURGERY    OF    THE    NOSE.    TILROAT.    AND    EAR. 


The  Processus  Mastoideus. 

The  mastoid  process  is  surgically  the  most  important  part  of  the 
temporal  bone.  Most  of  the  serious  complications  arising  in  the  course 
of  suppurativo  middle  ear  disease  develop  from  disease  of  this  proc- 
ess and  the  operations  undertaken  for  the  relief  of  these  complications 
begin  with  an  exenteration  of  the  mastoid. 

The  outlines  of  the  mastoid  process  present  a  cone-shaped  appear- 
ance, the  apex  of  the  cone  pointing  downward,  the  bast1  of  the  cone 
uppermost.  The  size  in  the  adult  is  not  constant.  The  outer  surface 
is  more  or  less  rounded  or  flattened  depending  largely  on  the  size.  In 


Adult    temporal    bone,    showing    the    typical    relation    of   the    linea    tcin- 
oralis    extending    in    a    horizontal    direction    back    from    the    external    canal. 


tin-  well  developed  process  the  outer  surface  is  more  rounded   while  ii: 
the  >ma!l  process  the  surface  is  more  flattened. 

The  markings  on  the  outer  surface  of  the  mastoid  process  are  of 
importance.  They  serve  as  a  guide  in  making  an  opening  into  the 
antruin.  The  base  of  the  mastoid  is  marked  off  by  a  horizontal  ridu'e, 
a  continual  ion  of  the  root  of  the  zygoma.  This  is  known  as  the  linea 
temporal]*  and  i>  constant  although  not  developed  as  prominently  in 
some  cases  as  in  others.  The  linea  temporalis  usually  extends  directly 
hack  from  and  on  the  same  plane  with  the  root  of  the  zygoma.  (Fig. 
•• )  It  lie-,  therefore,  a  little  above  the  external  meatiis.  In  some 
cases,  however,  it  curves  down  around  the  upper  posterior  margin  of 


Tin-:  sri«;ic.\i,  ANATOMY  OK  TIIK  KAI;. 

the  external  meatus  and  lakes  its  horizontal  course  I'roni  about  the 
middle  of  the  opening  of  the  external  incatus.  (Fig.  S-k )  In  other 
cases  the  linea  temporalis  takes  a  sharp  curve  upward  immediately 
back  of  the  upper  posterior  margin  of  the  external  ineatus.  (Fig.  80.) 
It  is  important  to  understand  these  variations  since  this  ridge  often 
serves  as  a  guide  in  opening  the  antruin  and  as  a  landmark  indicating 
the  line  of  separation  between  the  mastoid  and  the  middle  brain  fossa. 
In  keeping  below  the  linea  temporalis  when  opening  the  mastoid  proc- 
ess there  should  lie  no  danger  of  entering  the  middle  fossa.  The  cases 
in  which  the  linea  teinporalis  takes  a  sharp  curve  upward  just  back 
of  the  external  ineatus  are  exceptions.  Here  the  middle  fossa  can 


Fig.  84. 

Adult  temporal  bone  showing  the  linea  temporalis  making  a  marked 
curve  down  along  the  posterior  border  of  the  external  meat  us  before  turn- 
ing backward.  (Anatomic  variation.) 

be  readily  entered  by  chiseling  directly  inward  from  beneath  this 
ridge.  As  a  guide  for  finding  the  antrum  the  linea  temporalis  can 
usually  be  relied  on.  The  opening  is  made  immediately  below  the 
ridge  quite  close  to  the  meatus,  and  the  direction  of  the  external 
meatns  followed  until  the  antrum  is  reached.  There  is  but  one  type 
of  process  in  which  this  method  could  fail  to  lead  to  the  antrum. 
This  is  when  the  linea  temporalis  curves  down  along  the  pos- 
terior margin  of  the  external  meatus  before  coursing  backward.  (Fig. 
84.)  In  these  cases  the  opening  made  into  the  mastoid  as  indicated 
could  readily  miss  the  antrum  and  might  lead  to  an  injury  of  the  facial 
nerve. 


no 


OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 


Another  constant  landmark  on  the  outer  surface  of  the  temporal 
bone  is  the  spina  supranieatuni  located  at  the  upper  posterior  margin 
of  the  external  meatus.  (Figs.  74  and  77.)  This  is  a  small  roughened 
area  for  the  attachment  of  the  superior  ligament  of  the  auricle.  The 
size  of  the  spine  varies.  It  is  usually  quite  conspicuous  but,  especially 
in  children,  it  may  be  so  small  as  to  escape  detection.  As  a  guide  in 
opening  the  antrum  it  can  always  be  relied  upon  as  its  position  at  the 
upper  posterior  margin  of  the  external  meatus  is  constant.  The 
antrum.  which  lies  some  distance  out  along  the  upper  posterior  wall 
of  the  external  meatus,  is  readily  reached  by  making  an  opening  in  the 
mastoid  just  back  of  the  suprameatal  spine  and  following  the  direction 
of  the  external  meatus.  To  lay  off  an  imaginary  triangle  in  this  local- 


EA    TEMPORALIS 


del. 


Fig.  85. 

Adult   temporal   bone  showing  the  linea   temporally   making  a   curve  "up- 
ward at  the  posterior  margin  of  the  external  meatus.    (Anatomic  variation.) 

ity  before  making  the  opening  into  the  antrum  would  only  complicate 
the  situation  and  lead  to  confusion  in  the  mind  of  the  beginner.  The 
simplest  method  of  finding  the  antrum  when  the  suprameatal  spine 
can  be  recognized  is  the  direction  given  above.  In  all  cases  in  which 
the  spine  cannot  be  made  out  no  difficulty  will  be  experienced  in  locat- 
ing t  he  ant  rum  if  it  be  kept  in  mind  that  t  his  cavity  lies  above  the  upper 
posterior  wall  of  the  external  meatus  a  short  distance  external  to  the 
drum  membrane.  'The  opening  in  the  mastoid  should  be  made  close  to 
the  external  meatus  just  below  an  imaginary  line  passing  through  the 
upper  margin  of  the  external  meatus  and  the  occipital  protuberance. 
II  1h<'  opening  follows  closely  the  direction  of  the  external  meatus  one 
cannot  fail  to  find  the  aiilriini  if  that  cavity  has  not  been  completely 


THE  SURGICAL,  ANATOMY   OK  T.I  IK  KAK. 


111. 


obliterated,  as  it  may  bo  in  rare  eases  of  chronic  suppuration  of  the 
middle  ear. 

Other  markings  on  the  outer  surface  of  the  niastoid  are  the  open- 
ing for  the  emissary  niastoid  vein,  the  tympanomastoid,  and  the  potro- 
squamosal  sutures.  The  opening  of  the  emissary  niastoid  vein  is  along 
the  posterior  margin  of  the  niastoid.  (Fig.  84.)  it  frequently  repre- 
sents a  point  of  increased  tenderness  in  cases  of  thrombosis  of  tin- 
lateral  sinus.  The  location  of  the  opening  should  be  kept  in  mind  when 
operating  on  niastoid  cells  located  along  the  posterior  margin  of  the 
process.  The  tympanomastoid  suture  is  seen  along  the  posterior  mar- 
gin of  the  external  meatus.  It  marks  the  separation  between  the  part 
of  the  posterior  wall  of  the  meatus  formed  from  the  tympanic  bone  and 


Section   through   niastoid    process,   antrum   tympanicum,    and     external 
oanal.     (Pneumatic  type.) 

that  formed  from  the  niastoid  process.  The  petrosquamosal  suture  is 
well  marked  in  the  young  child  but  is  usually  quite  obliterated  in  the 
adult. 

The  niastoid  process  in  the  adult  usually  contains  pneumatic 
spaces  which  communicate  with  the  antrum  and  are  known  as  niastoid 
cells.  In  the  new-born  there  is  an  absence  of  a  niastoid  process  and  of 
niastoid  cells.  The  antrum,  which  is  in  reality  part  of  the  tympanum 
and  is  known  as  the  antrum  tympanicum,  exists  in  the  new-born.  As 
the  niastoid  process  develops  pneumatic  spaces  develop  and  as  a  rule 
completely  fill  the  process.  (Figs.  79,  86,  87.)  These  cells  often  extend 
beyond  the  confines  of  the  niastoid  process  forward  into  the  root  of 
the  zygoma  and  posterior  into  the  occipital  bone.  The  cells  lying  near 
the  antrum  are  as  a  rule  small  in  size.  The  cells  occupying  the  tip  of 


11 J 


OPERATIVE    SURliERY    OF    THE    NOSE,,    THROAT,    AXD    EAR. 


the  mastoid  and  those  lying  along  the  posterior  margin    are    usually 
much  larger.    (Fig.  7!',  S(>,  87.)    lu  Figs.  88  and  81)  is  shown  an  unusu- 


•'CESSL'S    MASTOIDEUS 


Pig.  87. 
Pneumatic  type  of  mastoid.     Larger  cells  arranged  along  the  periphery. 

ally  large  mastoid  cell  outside  the  mastoid  process  lying  internal  to 
the  diagastric  groove.  Such  a  mastoid  cell  is  especially  dangerous  be- 
cause in  the  first  place  a  suppuration  .here  could  produce  no  symptoms 


Fig.   SS. 

Fij^s.  XX  and  S'.t.  Section  through  teni])oral  bone.  Section  passes 
through  nntruiii,  vestibule  and  internal  meatus.  Large  pneumatic  cell  de- 
ve|o|)i.(|  internal  to  the  digastric  groove.  (Anatomic  variation.) 

over  the  outer  sui-face  of  the  mastoid  and  in  the  second   place  such  a 
cell   might    readily  escape  detection    when    operating    on     the    mastoid 


TIIK  srUCK'AL  ANATOMY  OF  TIIK   KAII. 


process.  The  mastoid  cells  ;ill  communicate  with  the  autrum  and  al- 
though the  walls  separating  adjoining  cells  usually  show  dehiscences 
cells  may  retain  their  own  openings  leading  to  the  aiitrum.  In  this 
way  it  is  possible  for  a  large  cell  at  the  tip  of  the  mastoid  to  communi- 
cate with  the  autrum  through  its  own  channel  and  without  communi- 
cating with  adjoining1  cells.  'Fhis  condition  may  explain  the  occurrence 
of  an  isolated  abscess  in  t  he  tip  of  1  he  mastoid  process. 

The  process  of  pneumati/ation  of  the  mastoid  is  often  incomplete 
so  that  mastoid  cells  are  formed  in  but  a  part  of  the  mastoid.  In  such 
cases  the  cells  are  located  close  to  the  antrum  while  the  tip  of  the  proc- 
ess and  the  posterior  margin  are  free  from  air  cells.  (Figs.  *<>,  90,  1)1.) 


Fig.  90. 

Section  through  temporal  bone,  showing  relation  of  the  horizontal 
canal  and  facial  canal  to  the  middle  ear  chambers:  also  relation  of  the 
carotid  and  bulbar  jugnlaris  to  the  cavuni  tympani. 

In  other  cases  no  mastoid  cells  whatever  exist.  (  Figs.  9'J  and  9  .'•>.)  Here 
the  process  is  Hatter  and  smaller  than  normal  and  the  size  of  the  an- 
trum also  is  quite  small.  In  other  words  the  whole  impression  one  gets 
from  an  examination  of  this  type  of  mastoid  is  that  of  an  undeveloped 
infantile  condition.  It  is  this  type  of  mastoid  process  that  is  found  in 
cases  of  chronic  suppurativc  otitis  media  dating  from  early  childhood. 
Mr.  Cheatle  interprets  these  facts  as  indicating  that  cases  of  acute 
purulent  otitis  media  are  more  inclined  to  become  chronic  when  occur- 
ring in  the  non-pneumatic  type  of  mastoid.  Others  are  inclined  to  be- 
lieve that  the  lack  of  pnemnatization  in  such  cases  is  itself  the  direct 
result  and  not  the  cause  of  the  chronic  suppuration.  The  suppuration 
beginning  in  early  childhood  before  the  development  of  the  mastoid 


OPERATIVE    SUIUiEKY    OF    THE    XOSE,    THROAT,,    AND    EAR. 


has  progressed  vci-y   far  hinders  its   further  development;  the  result 
beini>'  these  cases  of  complete  absence  of  mastoid  cells.     This  condition 


UDITORIUS    EXTERNUS 


Fig.  111. 

Section  through  the  mastoid  process,  showing  but  partial  pneumati- 
zation.  A  few  small  mastoid  cells  near  the  antrum  are  all  that  have 
formed. 


l)ipl<Hic   type  of   mastoid.     Complete  absi  nee  of   pneumatic   spaces.    An- 
trum   tympanicum    contracted. 

should  not  he  confused  with  the  process  of  osteosclerosis  or  hardening 
of  the  honi-  -iirroiindiim'  as  a  rule  a  cholesteatoma  formation  in  the  an- 


TIIK  STUCICAL  AXATO.MV   o  K   TIIK    KAI!.  1  1  .) 

•rum.  Tlie  1'oof  of  the  mastoid  is  a  thin  shell  of  bone  which  separates 
the  antrum  and  the  inastoid  cells  from  the  middle  brain  fossa.  Over 
the  antrum  it  is  called  the  teginen  antri.  Dehiscence  in  the  bone  fre- 
quently exists  so  that  only  the  lining  of  the  mastoid  cells  and  the  dura 
separates  the  cells  from  the  brain  cavity.  (Figs.  77,  90,  94,  !).").) 

A  number  of  important  structures  come  into  close  relation  with 
the  mastoid  process.  The  sigmoid  curve  of  the  lateral  sinus  lies  in- 
ternal to  this  process  and  encroaches  more  or  less  on  spaces  of  th" 
mastoid.  (Fig.  S± )  The  distance  separating  this  sinus  from  the  pos 
terior  wall  of  the  external  nieatus  varies  in  different  individuals.  I'su- 
ally  there  is  ample  space  between  the  sinus  and  the  posterior  wall  of 
the  nieatus  to  permit  of  a  wide  opening  into  the  antrum.  In  other 
cases  the  sinus  lies  so  close  to  the  nieatus  wall  that  the  opening  into 


Section  through  adult  temporal  bone,  showing  persistence  of  infantile 
type  with  absence  of  pneumatic  spaces  in  the  mastoid.  The  relations  of  the 
horizontal  and  facial  canals  to  the  middle  ear  spaces. 

the  antruin  lias  to  he  made  by  working  along1  the  upper  posterior  wall 
of  the  nieatus  instead  of  posterior  to  the  suprametal  spine.  The 
location  of  the  sigrnoid  curve  is  usually  the  same  on  hoth  sides.  The 
important  relation  of  the  facial  canal  to  the  inastoid  has  already  been 
discussed.  It  is  important  to  remember  that  mastoid  cells  may  develop 
in  close  proximity  to  the  facial  canal  and  that  these  cells  may  lie  deeper 
than  the  facial,  that  is  internal  to  it.  The  facial  nerve  is  most  readily 
injured  in  its  course  through  the  tympanum  or  at  the  point  where  it 
makes  the  heud  downward  toward  the  stylomastoid  opening.  (Figs. 
77,  80,  81,  90,  92,  94.) 

The  horizontal  semicircular  canal  forms  a  prominence  in  the  floor 
of  the  antrum  where  its  hard  ivory-like  capsule  can  readily  he  recog- 
nized, when  opening  the  antrum,  by  its  smooth  glistening  appearance. 
Its  position  is  such  that  should  the  cavity  of  the  antrum  be  mistaken 


11G 


OPERATIVE    SUHCKHV    OF    THE    XOSE,    THROAT,    AND    EAR. 


for  a  mastoid  cell  a  single  stroke  of  the  chisel  in  an  attempt  to  pene- 
trate further  might  readily  open  the  canal.  Its  position  in  a  measure 
protects  the  facial  nerves  from  injury  when  operating  on  the  mastoid, 
for  its  hard  capsule  forms  a  partial  covering  for  the  facial  canal  just 
back  of  the  oval  window.  (Figs.  SO,  90,  94,  Of).)  The  superior  semi- 
circular canal  encroaches  at  times  on  the  anterior  inner  wall  of  the 
antrum.  (Fig.  9(5.)  In  antrum  disease  it  is  possible  for  an  erosion 
into  the  superior  canal  to  occur.  This  canal  is  not  exposed  to  injury 
in  operating  on  the  mastoid  as  is  the  horizontal. 


Fig.  f»4. 

Soft  ion  through  adult  temporal  bone,  showing  the  relations  of  the 
carotid  to  the  cavuni  tyinpani  and  the  structures  in  the  floor  of  the  reces- 
sus  opitympanicus. 

Cavum  Tympani. 

Anatomically  the  tympanic  cavity  forms  but  a  part  of  a  larger 
cavity  which  includes  the  aiilrum  tympanicum  and  the  passage  between 
I  hoc  two.  the  recessus  epitympanicus.  (Figs.  S0-9f). )  Pathologically 
also  these  chambers  should  be  considered  together  as  they  are  usually 
involved  in  the  same  process.  The  division  of  the  passage  way  from 
tin-  t  vmpaiiimi  to  the  antrum  into  two  parts,  an  attic  and  aditus,  is  not 
feasible  anatomically.  (  Fig.  95.) 

The  inner  wall  of  the  tympanic  cavity  is  formed  largely  by  the 
capsule  of  the  labyrinth.  The  first  turn  of  the  cochlea  produces  a 


117 


TIIK  Sl'HCICAL  ANATOMY   OK  TIIK  KAK. 


prominence  just  posterior  to  the  renter  to  which  the  term  promontory 
is  given.  Just  above  the  promontory  is  an  oval  opening  into  the  vesti- 
bule of  the  labyrinth  railed  the  I'enestra  vestibuli.  This  is  the  oval 
window  in  which  the  foot  plate  of  the  stapes  is  attached.  The  win- 
dow itself  is  at  the  bottom  of  a  depression  out  of  which  only  the  head 
of  the  stapes  and  a  small  part  of  the  crura1  project,  .lust  posterior  to 
the  promontory,  lying  but  a  couple  of  millimeters  from  the  oval  win- 
dow, is  the  opening  into  the  tirst  turn  of  the  cochlea  called  the  fenestra 
cochlea1.  This  is  the  round  window  covered  over  by  a  membrane  which 
separates  the  tympanum  from  the  srala  tympani.  Directly  posterior 
to  that  part  of  the  promontory  which  separates  the  oval  from  the  round 
window  is  a  depression  often  extending  under  the  canal  for  the  facial 


Section    through    mastoid,    eavum    tympani,    tuba    auditiva.    showing    a 
large  tubal  cell. 

nerve.  This  depression  is  known  as  the  sinus  tympanicus.  It  is  dii'li- 
cult  to  smooth  out  this  pocket  when  performing  the  radical  mastoid 
operation.  A  conspicuous  marking  on  the  inner  wall  of  the  tympanum 
is  the  canal  for  the  tensor  tympani  muscle.  This  lies  just  above  the 
tympanic  orifice  of  the  Eustachian  tube.  The  processus  eochleari- 
formis  which  forms  the  posterior  end  of  this  canal  projects  out  a  short 
distance  over  the  anterior  margin  of  the  oval  window.  (Fig.  !)4.)  The 
relation  of  the  facial  canal  to  the  inner  wall  of  the  tympanum  is  of 
great  surgical  importance  as  the  facial  nerve  in  its  course  through  the 
tympanum  is  covered  by  an  extremely  thin  delicate  covering  of  hour 
which  can  readily  be  fractured  by  the  use  of  a  curette.  The  nerve  en- 
ters the  tympanum  in  front  of  and  just  above  the  oval  window.  Its 
course  is  more  or  less  horizontal  until  just  posterior  to  the  oval  win- 


118 


OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT.    AND    EAR. 


dow  it  curves  downward  toward  the  stylomastoid  opening.  (Figs.  80, 
si,  90,  9.'!,  94,  9(>.)  The  prominence  formed  by  the  horizontal  semicir- 
cular canal  in  the  floor  of  the  passage  from  the  antrimi  into  the  tym- 
panum projects  out  beyond  tin.1  facial  canal  and  in  this  way  serves 
often  to  protect  the  nerve  from  injury  when  operating  in  this  region. 
The  root'  of  the  tympanum  is  formed  by  a  plate  of  bone  separating 
this  cavity  from  the  middle  fossa.  This  is  called  the  teamen  and  is 
often  extremely  delicate.  (  Figs.  77,  SO,  90,  94,  95,  98.)  In  the  new-born 
it  is  crossed  by  the  suture  between  the  squamous  and  petrous  bones 
through  which  blood  vessel  communications  extend  between  the  dura 
and  the  membrane  lining  the  tympanum.  Through  this  tegmen  sup- 


Fig.   J»6. 


Section  through   the  mastoid  and  tympanic  cavity,  showing  the  relation 
of   the    horizontal    and    superior   canals   to   the   antrum. 

purative  disease  in  the  tympanum  frequently  penetrates  into  the  brain 
cavity. 

The  floor  of  the  tympanum  contains  a  number  of  depressions 
called  tympanic  cells.  These  cells  arc  occasionally  quite  extensive  in 
which  case  it  becomes  difficult  if  not  quite  impossible  to  clean  them  out 
entirely  in  operating  on  the  tympanum.  (Fig.  97.)  The  floor  of  the 
tympanum  extends  somewhat  deeper  than  the  floor  of  the  external 
meatii.-.  This  depression  is  called  the  recessus  hypotympanicus.  The 
relation  of  the  bulb  of  the  jugular  to  the  floor  of  the  tympanum  is  such 
that  infection  occasionallv  extends  from  the  tympanum  directly  to  the 


T1IK  SritClCAI.  ANATOMY   OF   'III 

hull).  The  hull)  is  frequently  exposed  to  injury  when  r.u retting  the 
floor  of  the  tympanum.  In  most  eases  the  hull)  is  separated  from  the 
tympanum  hy  a  thick  wall  of  hone.  (  Fig.  90.)  In  other  cases  the  hull) 
forms  a  prominence  in  the  floor  of  this  cavity.  11  is  then  covered  hy 
an  extremely  thin  shell  of  hone  readily  hrokeu  hy  the  curette.  (  Fig. 
1)8.) 

In  the  anterior  wall  of  the  tympanum  is  located  the  tympanic  ori- 
fice of  the  Eustachian  tuhe.  (  Figs.  82  and  !).">.)  The  internal  carotid 
lies  directly  in  front  of  the  tympanum  from  which  it  is  separated  hy 
a  thin  plate  of  hone.  (Figs.  SO,  Si',  DO,  94.)  In  performing  the  radical 
mastoid  it  is  important  to  rememher  that  the  carotid  lies  helow,  that 
is  internal  to  the  Eustachian  tuhe.  In  order  to  avoid  injuring  this  ves- 
sel the  pressure  of  the  curette  in  the  month  of  the  tuhe  must  he  directed 
upward,  that  is  outward.  The  mesial  wall  of  the  tuhe  should  not  he 


Horizontal  section  through  the  temporal  bone  seen  from  below.     A  laruc 
tympanic   cell   developed   near   the   floor   of   the   tympanum. 

curetted.     Pneumatic  cells  are  frequently  found  opening  into  the   Fu 
stachian  tuhe  near  the  tympanum.    These  are  the  tuhal  cells  and  at 
times  they  are  quite  extensive.    (Fig.  9f).)    On  account  of  the  relation 
of  the  internal  carotid  it  is  often  not  feasihle  to  eradicate  these  tuhal 
cells  when  performing  the  radical  mastoid  operation. 

Tn  the  posterior  wall  of  the  tympanum  is  located  the  opening  into 
the  antrum.  (Figs.  94  and  9f>.)  This  opening  occupies  ahout  the  up- 
per third  of  the  posterior  wall.  The  canal  for  the  facial  nerve  forms 
a  slight  prominence  along  the  mesial  wall  of  this  opening.  (Figs.  DO  and 
94.)  At  the  lower  margin  of  the  opening1  the  facial  canal  enters  the 
posterior  wall  of  the  tympanum.  Toward  the  Moor  of  the  tympanum 
this  canal  recedes  more  and  more  from  the  posterior  wall  of  the  cavum 
tympani.  (Figs.  80  and  81.)  A  small  houy  prominence  just  hack  of  the 
oval  window  contains  an  opening  for  the  transmission  of  the  tendon  of 


L'O 


OPERATIVE    SUROEKY    OF    THE    XOSE,    THROAT,    AND    EAR. 


the  stapedius  muscle.  This  prominence  is  called  the  eminentia  pyra- 
midalis.  (Fig.  J)4.)  The  depression  in  the  posterior  wall  of  the  tym- 
panum, called  the  sinus  tympanicus,  lies  directly  under  the  eminentia 
pyramidal  is. 

The  external  or  outer  wall  of  the  tympanum  is  formed  chiefly  by 
the  membrana  tympani.  At  the  floor  of  the  tympanum  is  a  depression, 
the  recessus  hypotympanieus,  the  external  Avail  of  which  is  formed  by 
the  floor  of  the  bony  meatus.  (Fig.  7(5.)  At  the  upper  part  of  the  tym- 
panum is  the  recessus  epitympanicus,  the  outer  wall  of  which  is 
formed  bv  the  bone  forming1  the  roof  of  the  external  meatus.  (Fig. 


Fig.  98. 

Section  through  temporal  bone,  showing  relation  of  the  bulbus  jugu- 
laris  to  cavum  tympani  and  relations  of  the  cochlea  and  facial  canal  to  the 
cavum  tympani. 

7<i. )  hi  removing  the  external  wall  of  1  he  so-called  attic,  there  is  danger 
of  injuring  the  facial  nerve  as  this  structure  in  its  course  through  the 
tympanum  lies  directly  internal  to  the  lower  margin  of  the  external 
wall  of  1  his  chamber. 

When  curetting  out  the  tympanic  cavity  great  care  must  he  taken 
on  account  of  the  danger  of  injuring  important  structures.  Jn 
the  floor  of  the  tympanum  is  tin-  recessus  hypotympanieus  and  the 
tympanic  cells  which  frequently  require  cleaning  out  when  perform- 
ing the  radical  operation.  Here  the  danger  of  injuring  the  hull)  of  the 
jugular  must  lie  kept  in  mind.  Along  the  posterior  wall  of  the  tym- 
panum are  several  depressions,  the  largest  of  which,  the  sinus  tym- 
panicu>.  extends  often  under  the  canal  for  the  facial.  These  cells  are 


THK  SrKCICAL  ANATOMY   OK   T  1 1  K   KAIJ.  1  '2  1 

exposed  only  by  removing  the  ledge  of  hone  in  t'ronl  of  the  facial  canal 
in  the  lower  half  of  the  posterior  wall  of  t  lie  meat  us.  (  Figs,  so  and  si.) 
In  the  floor  of  the  Kustachian  tnhe  near  its  tympanic  orifice  are  the 
tnbal  cells,  which  must  he  opened  with  great  caution  on  account  of  the 
location  of  the  internal  carotid  just  anterior  and  internal  to  the  tym- 
panum and  internal  to  the  Eustacliian  tnhe.  The  roof  of  the  tym- 
panum, the  teamen  tympani,  separates  this  cavity  from  the  middle 
fossa.  It  is  a  fragile  shelf  of  hone  easily  perforated  by  a  curette.  In 
curetting  the  inner  wall  of  the  tympanum  the  region  just  below  and  in 
front  of  the  prominence  for  the  horizontal  canal  should  be  avoided  be- 
cause the  facial  canal  crosses  the  tympanum  here  and  in  this  region  is 
the  oval  window  with  the  stapes.  A  dislocation  of  the  latter  may  lead 
to  an  infection  of  the  labyrinth. 

The  relations  of  the  lateral  sinus  are  important  to  keep  in  mind 
not  only  when  operating  on  the  sinus  itself  but  whenever  an  opening 
into  the  mastoid  is  made.  The  variations  in  the  location  of  the  sigmoid 
curve  of  this  sinus  are  such  that  unless  they  are  understood  there  is 
often  great  danger  of  opening  the  sinus  when  performing  the  simple 
mastoid  operation.  The  sigmoid  usually  lies  far  enough  posterior  to 
the  external  meatus  to  permit  of  a  free  opening  into  the  antrum.  (Fig. 
82.)  It  frequently  projects  forward,  however,  so  close  to  the  posterior 
wall  of  the  external  meatus  that  a  free  opening  from  the  surface  of 
the  mastoid  into  the  antrum  is  obstructed.  It  usually  lies  at  a  consid- 
erable distance  from  the  surface  of  the  mastoid  but  in  those  cases  in 
which  the  sinus  is  pushed  forward  it  approaches  closer  and  closer  to 
the  surface  of  the  mastoid.  It  can  be  seen  in  some  cases  after  the 
periosteum  has  been  removed,  as  a  bluish  discoloration  from  the  sur- 
face of  the  mastoid.  In  all  cases  the  cortex  of  the  mastoid  should  be 
removed  with  caution  until  the  location  of  the  sinus  has  been  deter- 
mined. In  rare  cases  there  is  a  congenital  absence  of  the  lateral  sinus 
on  one  side.  The  author  has  one  such  preparation  in  his  collection. 
Xear  the  upper  posterior  margin  of  the  mastoid  process  the  sinus 
takes  a  horizontal  direction  backward.  At  about  the  level  of  the  floor 
of  the  tympanum  the  sinus  turns  inward  and  somewhat  forward  in  a 
horizontal  direction  towards  the  bulb. 

The  position  of  the  bulb  of  the  jugular  and  its  relation  to  the  sur- 
rounding structures  must  be  understood  by  the  surgeon  who  under- 
takes to  operate  on  the  mastoid.  In  cases  of  infection  it  becomes  neces- 
nary  to  expose  the  bulb  and  to  lay  it  freely  open.  The  relation  of  the 
bulb  to  the  cavum  tympani  has  already  been  described.  When  the  bulb 
occupies  that  relation  to  the  lloor  of  the  tympanum  which  is  shown  in 


122 


OPERATIVE    STHCERY    OF    THE    NOSE,,    TH  HO  AT,    AXD    EAR. 


Fig.  1'S  or  in  Fig.  !M»  an  exposure  of  the  bulb  by  operating  through  the 
tynipaiiuin  is  feasible. 

The  location  of  the  bulb  varies,  however,  even  more  than  does  that 
of  the  lateral  sinus.  In  most  cases  the  bulb  makes  but  a  shallow  inden- 
tation in  the  lower  surface  of  the  temporal  bone,  so  that  a  curette 
passed  forward  along  the  lateral  sinus  will  remove  clots  located  in  it. 
In  these  cases  it  is  separated  from  the  floor  of  the  tympanum  by  a 
thick  layer  of  bone.  In  other  cases  the  dome  of  the  jugular  bulb  is 
pushed  upward  higher  and  higher  along  the  posterior  wall  of  the 
petrous  bone.  In  these  cases  the  appearance  is  not  unlike  an  erosion 
produced  by  an  eddy  in  a  stream.  The  extent  to  which  the  bulb  is 
pushed  upward  in  these  cases  is  often  surprising.  Occasionally  the 
bulb  extends  1o  the  highest  margin  of  the  petrous  bone.  In  Fig.  100  is 


CANALIS   CAROTICUS 


Fig.   !)!». 

Horizontal  section  through  the  temporal  bone  seen  from  above,  showing 
the  relations  of  the  bulbus  jugularis  to  the  lateral   sinus. 

shown  a  case  in  which  the  bulb  extends  through  the  superior  margin  of 
the  petrous  bone  and  in  its  course  ((Illiterates  part  of  the  posterior  wall 
of  the  internal  nieatus  as  well  as  the  bony  covering  of  the  aqua'ductus 
vest  ibiili. 

The  surest  route  for  the  exposure  of  the  jugular  bulb  is  to  fol- 
low along  the  course  of  the  lateral  sinus  until  the  bulb  is  reached.  By 
chiseling  along  in  front  of  the  sinus  a  layer  of  bone  can  be  removed 
posterior  to  the  facial  canal  which  will  usually  permit  of  a  more  or  less 
free  exposure  of  the  bulb,  depending,  of  course,  on  whether  the  bulb 
is  shallow  or  deep.  The  thickness  of  the  bone  thai  can  be  removed  in  this 
way  along  the  anterior  wall  of  the  sinus  without  an  injury  to  the  facial 
nerve  is  often  as  much  as  ()..")  cm.  (  Fig.  !>!).)  Care  must  be  taken  in  mak- 
ing Ihi-  opening  into  the  bulb  not  to  extend  the  chiseling  too  far  up 
alonu'  the  posterior  surface  of  the  petrous  bone  for  here  there  is  danger 
ot  opening  into  the  posterior  semicircular  canal. 


'I' I  IK  Sl'ltCIC  A  I,   ANA 

III  connection  with  the  surgical  relation  of  the  lateral  sinus  it 
should  he  mentioned  that  this  structure  serves  as  the  best  guide  for 
the  opening  of  a  cerebellar  abscess.  rrhese  abscesses  lie  usually  some- 
where along  the  posterior  surface  of  the  petrous  bone  in  front  of  the 
lateral  sinus.  To  attempt  to  drain  such  an  abscess  by  an  opening  back 
of  the  sinus  is  more  difficult  because  of  the  great  distance  from  the  sur- 
face. The  best  route  by  which  to  reach  these  abscesses  is  by  making 
an  opening  in  front  of  the  lateral  sinus.  If  the  anterior  wall  of  the 
lateral  sinus  is  followed  and  the  chiseling  is  not  carried  too  far  for- 
ward it  is  possible  to  expose  the  cerebellum  without  an  injury  of  the 


Fig.   100. 

View  of  the  posterior  aspect  of  the  temporal  bone,  showing  bulbus  jug- 
ularis  extending  to  the  upper  margin  of  the  petrous  bone.  (Anatomical 
variation.) 

posterior  semicircular  canal  provided  that  the  abscess  is  not  secondary 
to  a  labyrinth  suppuration. 

The  surgical  anatomy  of  the  labyrinth  is  best  explained  in  con- 
nection with  the  operation  on  the  labyrinth.  In  this  connection  atten- 
tion may  be  called  to  the  relations  of  the  labyrinth  to  the  middle 
ear  chambers.  In  the  cavum  tympani  the  capsule  of  the  labyrinth  is 
freely  exposed.  The  promontory  on  the  inner  wall  is  formed  by  the 
large  turn  made  by  the  beginning  of  the  basal  coil.  By  chiseling  from 
the  lower  edge  of  the  fenestra  vestibuli  a  free  opening  into  the  vesti- 
bule is  made  and  in  removing  the  promontory  free  drainage  of  the  coch- 
lea is  accomplished.  In  removing  the  promontory  the  relation  of 
the  bull)  of  the  jugular  shown  in  Fig.  i>8  should  be  kept  in  mind.  In 
just  such  a  case  the  author  has  opened  the  bulb  while  removing  the 


11*4  OPERATIVE    SURtiERV    OF    THE    NOSE,    THROAT;,    AND    EAR. 

promontory.  The  apex  of  the  cochlea  can  bo  exposed  by  chiseling  for- 
ward from  the  anterior  margin  of  the  oval  window.  The  apex  of  the 
cochlea  lies  internal  to  the  tympanic  orifice  of  the  Eustachian  tube. 
Its  relation  to  the  internal  carotid  lying1  just  posterior  or  external  to 
this  structure  makes  it  necessary  to  exercise  great  care  when  working 
in  this  region. 

Two  of  the  semicircular  canals  come  into  more  or  less  close  rela- 
tion to  the  middle  ear  cavities,  the  horizontal  and  the  superior.  The 
capsule  of  the  horizontal  canal  forms  a  white  glistening  prominence 
readily  seen  in  opening  the  antrum.  It  lies  in  the  floor  of  the  recessus 
epitympanicus  at  the  point  where  this  opens  into  the  antrum.  The  re- 
lation of  the  superior  canal  to  the  middle  ear  is  not  nearly  so  intimate. 
It  lies  just  above  the  anterior  end  of  the  exposed  part  of  the  horizontal 
canal.  In  this  way  its  anterior  cms  is  readily  exposed  by  chiseling 
above  the  prominence  of  the  horizontal  canal  and  directly  over  the  oval 
window.  Tn  opening  this  canal  the  position  of  the  facial  nerve  along 
the  upper  margin  of  the  oval  window  must  not  be  forgotten.  The  pos- 
terior semicircular  canal  does  not  come  into  close  relation  to  the  mid- 
dle ear.  It  can  be  reached  by  removing  the  triangular  piece  of  bone 
between  the  superior  and  the  horizontal  canals. 


CHAPTER    IV. 

EXTERNAL  OPERATIONS  ON  THE  LARYNX,  PHARYNX,  IPPER 
ESOPHAGUS,  AND  TRACHEA.* 

BY  GEORGE  W.  CRILE,  M.   I). 

Special  Difficulties  and  Dangers. 

The  teclmic  of  external  operations  upon  the  upper  air  passages  and 
the  esophagus  would  be  simple  enough  were  it  not  for  certain  special 
difficulties  and  dangers  peculiar  to  these  operations.  It  is  well  there- 
fore to  first  consider  these,  that  the  full  significance  of  the  various  steps 
:,:-i  the  operations  to  be  described  later  may  be  more  fully  appreciated. 

Pneumonia. — Pneumonia  following  operation  on  the  upper  air 
passages  is  due  in  most  instances  to  one  of  two  causes:  (a)  the 
inhalation  of  blood  or  mucus,  and  (b)  the  inhalation  of  infected  wound 
discharges.  These  injurious  inhalations  occur  usually  in  the  course  of 
the  operation,  although  occasionally  the  postoperative  oo/ing  is  in- 
haled. These  dangers  may  be  prevented  in  part  by  scrupulously  main- 
taining a  dry  field  during  the  entire  course  of  the  dissection.  This  is  ac- 
complished by  picking  up  every  vessel  large  enough  to  be  considered  at 
all,  either  before  dividing  it  or  immediately  after  it  lias  been  divided. 
In  this  manner  the  field  will  be  kept  so  clear  of  blood  that  all  an- 
atomic structures  may  be  easily  seen  and  identified.  During  the 
later  stages  of  the  dissection  the  vessels  which  have  been  picked  up 
may  be  ligated  with  either  light  catgut  or  light  silk.  While  this  man- 
ner of  dissection  may  at  first  seem  to  be  tedious,  it  will  in  the  end 
prove  the  quickest  method,  and  is  the  method  of  choice  in  dissections 
for  the  exposure  of  the  larynx,  pharynx,  trachea,  or  esophagus.  When 
the  field  of  operation  has  been  reached,  however,  the  prevention  of 
blood  inhalation  becomes  quite  a  different  problem,  because  the  blood 
supply  of  the  mucous  membrane  is  maintained  principally  by  terminal 
arterioles  which  cannot  be  effectively  controlled  by  ligation.  At  this 
point  in  the  operation  one  of  two  courses  may  be  adopted.  The 
patient  may  be  placed  in  a  head-down,  inclined  posture  at  such  an 
angle  that  the  blood  will  gravitate  away  from  the  lung:  or  by  the 
hypodermic  use  of  novocain  and  adrenalin  the  trachea,  the  larynx. 


126  OPERATIVE    STRCERY    OF    Till-:     NOSH,    THROAT.    AND    EAR. 

and  the  pharynx  may  be  entered  without  resultant  coughing  or  ma- 
terial oozing.  If  the  mucous  membrane  has  been  locally  anesthetized 
the  bleeding  may  usually  be  controlled  by  the  local  application  of 
pledgets  of  cotton  saturated  with  adrenalin  pressed  firmly  against  the 
bleeding  points  by  hemostatic  forceps.  The  further  control  of  hemor- 
vhage  depends  upon  the  circumstances  of  the  individual  operation.  If 
conditions  permit,  a  rubber  tube  which  snugly  Mils  the  trachea  or  even 
distends  it  will  entirely  control  the  dangerous  factor  of  blood  inha- 
lation. 

There  are  both  advantages  and  disadvantages  to  the  control  of 
hemorrhage  by  posture,  for  the  amount  of  hemorrhage,  especially  of 
venous  hemorrhage,  is  increased  by  gravity.  Then  too,  the  head-down 
position  is  less  favorable  for  the  operator.  The  direct  control  method 
has  the  advantage  of  light,  accessible  position  and  the  minimum  bleed 
ing.  The  author  has  rarely  found  it  necessary  to  resort  to  the  head- 
down  posture,  although  it  lias  sometimes  been  temporarily  used  during 
some  phase  of  an  operation.  Occasionally,  of  course,  a  great  emer- 
gency may  exist  in  which  the  head-down  posture  is  urgently  demanded. 

Local  Infection. — The  next  great  danger  associated  with  opera- 
tions on  the  upper  respiratory  tract  is  that  of  local  infection,  for  it 
may  happen  that  after  the  air  passages  have  been  opened  a  serious 
local  infection  will  spread  over  the  contiguous  territory  and  along  the 
deep  ] ilanes  of  the  neck.  'Fhe  occurrence  of  some  infection  must  be 
taken  for  granted,  but  it  is  for  us  to  consider  by  what  means  the 
amount  and  the  virulence  of  the  infection  may  be  diminished  and  how 
it  can  be  localized.  In  the  first  place,  the  danger  may  be  minimized 
in  advance  by  canvassing  all  of  the  contiguous  territories  and  mak- 
ing sure  that  there  are  not  present  any  active  foci  of  infection,  such 
as  decayed  teeth,  pyorrhea,  alveolar  abscesses,  discharging  sinuses. 
peritonsillar  abscess,  pharyngitis,  or  purulent  rhinitis.  At  the  time 
of  the  operation  itself  we  may  control  the  local  severity  of  the  infec- 
tion by  using  only  sharp  dissections  and  by  minimizing  to  the  utmost 
the  trauma  of  surrounding  tissues;  hv  leaving  no  oozing  of  blood;  by 
making  careful  decisions  as  to  the  immediate  closure  of  the  soft  parts 
overlying  the  wound;  and  by  using  iodoform  packing  if  there  must 
be  any  wound  in  the  soft  parts  of  the  throat  and  neck.  When  infection 
has  been  inaugurated  there  are  no  better  therapeutic  measures  than 
the  hot  pack-  and  the  inhalation  of  medicated  or  plain  steam. 

Mediastinal  Abscess. — After  pneumonia,  mediastinitis  and 
niediastinal  abscess  have  been  the  most  fatal  after-results  of  the 
operations  \ve  are  considering.  The  onset  of  infection  is  usually  a 
week-  or  ioi  days  after  the  operation,  and  is  characterized  by  a 


LARYNX,     PHARYNX,     ri'l'KH     KSOl'J  I  A< ;  I'S,    AM)    TI!A< '  1 1  KA  . 


steeplechase  temperature,  not  high,  and  always  re 
ing.  There  is  usually  but  little  pain,  and  the  course  of  the 
toward  slow,  but  certain  death.  In  many  respects  it  resembles  the 
retroperitoneal  abscesses  which  also  come  late,  are  almost  painless, 
progress  slowly,  show  a  steeplechase,  but  low  tempi-rat  lire  curve,  and 
(Mid  usually  in  death.  The  explanation  of  the  characteristic,  painless, 
tedious  and  fatal  course  of  mediastinal  abscess  is  probably  found 
in  the  fact  that  this  region  of  the  body  has  always  been  protected  from 
wounds  by  the  bony  chest  wall.  P>eiug  closed  to  wounds  through  the 
vast  periods  of  man's  evolution,  it  has  been  closed  likewise  to  infec- 
tion. The  tissue  of  this  protected  region,  therefore,  has  not  been 
(Midowed  with  the  elements  required  to  efficiently  meet  and  overcome 
infection  as  have  been,  for  example,  the  peritoneum  and  the  external 
parts  of  the  body.  In  view  of  this  fact,  we  must  guard  this  helpless 
territory  with  special  care. 

As  we  have  shown  that  preoperative  measures  may  in  large  de.irree 
prevent  the  extensive  course  of  local  infection,  so  the  danger  of 
mediastinitis  may  be  guarded  against  by  preoperative  protection.  If 
in  the  course  of  a  laryngectomy,  for  instance,  the  divided  trachea  is 
stitched  to  the  skin,  there  is  great  danger  that  subsequent  coughing 
will  cause  it  to  become  detached.  Its  moorings  having  been  lost,  it 
will  be  thrust  back  and  forth,  in  and  out  of  the  thoracic  box,  like 
the  piston  of  an  engine.  Mediastinal  infection  will  be  the  almost 
inevitable  result.  If,  on  the  other  hand,  the  free  (Mid  of  the  trachea 
is  not  fixed  by  sutures,  but  is  held  by  gauze  packing  about  it,  then 
the  trachea  will  retract  within  the  thoracic  cage  like  the  head  of  a 
turtle,  and  again  infection  must  result.  It  is  obvious,  then,  that  the 
trachea  should  be  so  fixed  by  preliminary  operation  that  there  may 
be  produced  an  invincible  barrier  of  granulations  extending  across 
the  base  of  the  neck  and  the  entrance  to  the  thoracic  cage.  There 
are  two  methods  by  which  this  may  be  done:  The  ordinary  simple 
tracheotomy  will  fix  the  trachea  and  will  stimulate  the  formation  of 
efficient  granulation  tissue;  or  exposing  the  trachea  and  the  lower 
larynx  and  packing  the  lateral  planes  of  the  neck  with  iodoform  gauze 
will  result  in  the  production  of  granulations  and  in  fixing  the  trachea 
so  firmly  that  coughing  cannot  break  its  moorings.  Each  of  these 
methods  of  itself  alone  has  certain  advantages  and  disadvantages.  The 
simple  tracheotomy  is  not  so  certain  a  safeguard  against  infection  of  the 
mediastinum  as  is  the  latter  method,  and  it  does  not  result  in  so  firm  a 
fixation  of  the  trachea  in  the  deeper  part  of  the  neck:  but  it  has  the 
advantage1  of  establishing  a  strong  defense  mechanism  in  the1  mucous 
membrane  of  the  trachea  itself.  On  the  other  hand,  tin1  packing  of 


ll!S  OPERATIVE    STRCERY    OF    THE    NOSE,    THROAT,    AND    EAR, 

the  (loop  planes  with  iodoform,  while  otherwise  an  ideal  protection, 
<loes  not  snp])ly  the  jtrotective  defenses  in  the  mucous  membrane  of 
the  trachea.  An  ideal  defense,  then,  is  found  in  a  combination  of  the 
two  operations,  that  is,  in  opening  and  packing  the  deep  planes  of  the 
base  of  the  neck,  and  at  the  same  seance  making  a  low  tracheotomy. 
By  this  means  the  mediastinum  is  put  under  strong  guard,  and  at  the 
same  time  the  later  teclmic  of  the  operation  is  measurably  reduced. 

Vagitis. — Though  a  less  frequent  risk  than  those  we  have 
described,  vagitis  represents  a  formidable  and  special  danger.  Tn  the 
course  of  the  convalescence  following  laryngectomy,  usually  after  the 
fourth  day,  a  group  of  new  symptoms  is  occasionally  introduced;  the 
pulse  becomes  very  rapid  and  irregular  in  rate  and  rhythm — it  may 
jump  from  90  to  140  in  a  few  minutes;  the  heart's  action  becomes 
tumultuous  at  times;  the  patient  is  quiet  or  perhaps  a  little  appre- 
hensive. Death  from  vagitis  has  been  reported,  though  in  the  author's 
oases  the  symptoms  passed  after  a  rather  boisterous  course  of  a  few 
days.  It  is  probable  that  the  trunks  of  the  vagi  have  become  involved 
in  the  wound  infection  and  as  a  result  these  nerves  have  been  ren- 
dered unfit  to  properly  conduct  stimuli.  Hence  there  arises  the 
striking  conflict  between  the  vagus  and  the  accelerator  control,  the 
picture  being  very  similar  to  the  immediate  effect  of  crushing  or 
dividing  both  vagi  simultaneously.  As  a  protection  against  this,  one 
might  utilize  the  well-known  physiologic  fact  that  the  division  of  one 
vagus  causes  no  notable  change  in  the  heart's  action.  In  the  course 
of  extensive  dissections  for  the  wide  excision  of  cancer  of  the  neck,  the 
author  lias  eight  times  excised  a  portion  of  the  trunk  of  one  vagus. 
('lose  observation  of  the  pulse  and  respiration  detected  no  change  nor 
was  any  later  alteration  observed.  Following  this  indication,  then, 
at  the  preliminary  operation  one  should  carry  the  dissection  on  one 
side  of  the  larynx  all  the  way  to  the  upper  margin  of  the  field  of  final 
operation,  and  should  pack  this  territory  with  iodoform  gauze  just 
as  the  deep  pianos  of  the  nook  are  packed.  P>y  this  procedure  one 
vagus  must  take  the  brunt  of  exposure  and  adjustment  before  the 
larynx  is  removed.  I>y  the  time  the  laryngectomy  is  done  this  vagus 
would  be  readjusted  and  ready  to  resume  its  function  in  case  it  was 
affected  at  all,  and  so  the  heavy  onslaught  of  the  vagi  upon  the  heart 
would  not  be  made  by  both  vagi  simultaneously.  In  the  case  in  which 
the  author  tried  this  plan  it  seemed  to  be  completely  effective.  When 
va iritis  has  become  established  there  is  little  that  can  be  done  to 
alleviate  it,  although  hot  applications  are  apparently  of  some  service. 

Reflex  Inhibition  of  the  Heart  and  Respiration  Through  Me- 
chanical Stimulation  of  the  Superior  Laryngeal  Nerves. — This  is  a 


LAHYNX,     IMIAHYNX,     flM'KH     KSOIMIACt'S,    AND    THACHKA.  120 

minor  phenomenon  peculiar  to  the  surgery  of  this  region,  but  it  is 
reported  to  have  resulted  in  several  deaths  and  has  caused  much 
anxiety  and  trouble  to  those  who  have  never  known  of  its  existence 
and  who  have  not  known  how  to  interpret  and  obviate  it.  In  a 
laryngectomy  the  terminals  of  the  superior  laryngeal  nerves  in  the 
larynx  and  on  the  surface  of  the  rima  glottidis  are  of  necessity  dis- 
turbed, and  the  trunks  of  these  nerves  are  divided  in  the  course  of 
operation.  The  function  of  the  laryngeal  nerves  is  the  protection  of 
the  pulmonary  tract  from  the  entrance  of  foreign  bodies.  The  slight- 
est touch  of  their  endings,  therefore,  causes  a  cough  reflex,  and  a 
strong  contact  will  cause  an  inhibition  of  respiration  and  of  the  heart. 
The  nerve  supply  of  the  trachea  has  no  such  function,  but  the  area  of 
distribution  of  the  inhibitory  nerve  endings  extends  over  a  part  of  the 
pharynx  and  a  part  of  the  posterior  nares  even.  Fortunately,  we  have 
an  absolute  protection  against  this  dramatic  and  sometimes  dangerous 
phenomenon,  in  the  hypodermic  administration  of  1  100  grain  atropin 
(adult  dose)  before  the  operation.  In  addition  a  spray,  a  local  appli- 
cation, or  the  local  hypodermic  injection  of  novocain  will  control 
absolutely  the  inhibitory  reflexes. 

Selection  and  Care  of  Tracheal  Cannula. — The  last  special  diffi- 
culty which  we  shall  consider  relates  to  the  after-care  of  the  patient, 
and  refers  to  the  selection  and  care  of  the  trachea!  cannula.  After 
trying  many  kinds  of  cannula1,  the  author  has  found  that  the  common 
male  or  female  curved  cannula,  or  plain  rubber  tubing  even,  will 
answer  all  purposes.  The  greatest  care  should  be  exercised  in  adjust- 
ing the  metal  tubes  so  as  to  prevent  pressure  necrosis.  Rubber  tubing 
is  preferred  by  some  patients,  but  the  metal  tubes  usually  are  best. 
A  rubber  tube  drawn  over  a  metal  tube  is  perhaps  the  easiest  to  wear, 
but  the  author  has  found  that  patients  become  careless  by  their 
familiarity  with  danger  and  will  wear  loose-fitting  tubes.  This  point 
was  strongly  impressed  on  the  author  by  the  difficulty  once  encount- 
ered in  extracting  a  rubber  tube  that  had  slipped  off  the  metal  tube 
and  had  been  carried  deep  into  the  trachea.  After  a  stormy  session 
in  which  the  patient  almost  suffocated,  the  tube  was  caught  by  groping 
deep  within  the  trachea  with  a  curved  hemostat  forceps  and  it  was 
extracted  while  the  patient  was  unconscious  from  asphyxia.  In  time 
all  laryngectomy  cases  get  along  without  tubes.  In  fact,  in  recent 
eases  the  author  has  been  able  to  dispense  altogether  with  tracheal 
tubes,  both  at  the  time  of  the  operation  and  ever  afterward,  and  the 
author's  patients  have  all  preferred  to  get  along  without  phonating 
apparatus. 


!.'!()  OPERATIVE    STHtiKHV    OF    THE    NOSE,    THROAT,    AND    EAR. 

Operations  on  the  Trachea. 

Tracheotomy. — A  tracheotomy  may  bo  high  or  low,  an  emergency 
or  a  planned  operation.  There  is  but  little  difference  between  the 
technic  of  the  high  and  the  low  tracheotomy,  but  there  is  a  vast  differ- 
ence between  planned  and  emergency  operations.  The  latter  will 
therefore  be  described  separately. 

Emergency  Tracheotomy. — Foreign  bodies  in  the  larynx  or 
trachea,  the  pressure  of  tumors,  the  closure  of  the  trachea  by  the  swell- 
ing of  previous  strictures,  the  pressure  of  an  abscess,  the  encroachment 
of  malignant  tumors  of  the  thyroid  or  other  tissues,  the  closure  of  the 
larynx  by  intralaryngeal  tumors,  at  first  gradual  but  finally  sudden, 
and  many  other  causes  of  obstruction  may  demand  an  emergency 
tracheotomy.  Then,  too,  the  trachea  may  collapse  during  the  re- 
moval of  a  large  obstructing  goitre — especially  if  the  operation  is 
being  performed  under  ether  anesthesia.  Whatever  the  cause,  this 
emergency  presents  one  of  the  most  dramatic  of  surgical  crises. 
I  nder  the  urgent  necessity,  it  is  usually  a  laryngotomy  and  not  a 
tracheotomy  that  is  performed.  But  in  the  presence  of  an  emergency 
when  a  life  is  dickering  fine  distinctions  are  lost. 

In  emergencies  which  occur  in  the  course  of  operations  upon 
natients  who  are  laboring  against  respiratory  obstruction  there  are 
several  very  important  points  to  be  considered  in  the  effort  to -prevent 
respiratory  collapse.  First,  the  patient  must  be  kept  free  from 
excitement, — by  morphin  and  atropin  if  personal  influence  be  insuf- 
ficient. I'tider  excitement  respiration  is  accelerated.  The  resultant 
increase  in  the  exchange  of  air  at  once  accentuates  the  diminished 
space  at  the  constriction  and  makes  the  patient  feel  acute  symptoms 
of  suffocation,  whereas  quiet  breathing  can  be  accomplished  easily 
through  a  smaller  aperture.  Second,  a  little  mucus  may  precipitate 
respiratory  obstruction.  Happily,  the  secretion  of  mucus  may  be 
wholly  controlled  by  the  use  of  atropin.  Third,  a  general  anesthetic 
is  absolutely  contraindicatod  when  a  patient  is  exerting  more  than 
the  normal  muscular  action  in  effecting  an  exchange  of  air,  especially 
when  he  is  iisinu'  the  extraordinary  muscles  of  respiration.  The  author 
ha>  >een  instances  of  the  fatal  error  of  giving  a  general  anesthetic  to 
>ueh  a  patient.  Inhalation  anesthesia  paraly/os  the  extraordinary 
mu>e|e>  of  respiration.  These  muscles  are  used  only  when  enough 
oxyiren  to  sustain  life  cannot  be  secured  by  the  action  of  the  ordinary 
muscles  of  respiration.  I  ndcr  these  circumstances  therefore  the 
extraordinary  mu>e|es  become  vital. 

Therefore,  in  cases  of  respiratory  obstruction   in   which   the  extra- 


LAKY.XX,     IMIAIIYXX,     I'l'I'KH     KSOl'l  I  A<  I  TS,    AND    TliACHKA.  l.'Jl 

ordinary  muscles  of  respiration  arc  used,  the  operation  musl  he  per- 
formed under  local  anesthesia — ami  it'  by  chance  there  is  no  local 
anesthetic  available  it  must  be  done  without  anesthesia  of  any  kind. 

The  ideal  state  for  operation  in  the  presence  of  partial  obstruction 
is  the  general  quiescence  produced  by  morphin,  local  anesthesia  beinu: 
secured  by  the  use  of  novocain.  When  an  emergency  tracheotomy  is 
to  be  performed,  it  is  best  to  put  the  patient  quickly  in  the  Trendelen- 
berg  posture  so  that  the  bleeding,  which  under  the  influence  of 
asphyxia  is  sure  to  be  increased,  may  not  be  inhaled  and  cause  a  septic 
bronchitis  or  pneumonia.  In  emergencies  the  probability  of  blood 
inhalation  is  so  great  that  the  patient  should  at  once  be  placed  in  the 
Trendelenberg  position.  The  trachea  should  not  be  opened  by  a 
plunging  incision,  a  procedure  which  has  brought  many  a  promising 
attempt  to  grief.  An  orderly  but  accelerated  dissection  whereby  the 
operator  may  distinctly  see  the  tracheal  rings  yields  the  quickest 
relief  even  in  the  hands  of  master  surgeons — indeed  it  is  by  performing 
controlled  operations  that  one  becomes  a  master  surgeon.  As  soon 
as  the  trachea  has  been  perforated  nothing  but  bad  technic  can  cause 
the  patient  to  suffocate.  If  the  soft  parts  are  sufficiently  retracted 
by  instruments  or  fingers  or  both  so  that  the  blood  is  kepi  out,  the 
patient  will  do  all  the  better.  As  for  the  tracheotomy  tube  any  piece 
of  rubber  tubing  will  answer.  In  the  absence  of  rubber  tubing  or 
tubing  of  any  sort  the  tracheal  lings  may  be  stitched  to  the  skin  on 
each  side.  After  an  emergency  opening  of  the  trachea  which  has  been 
performed  under  the  partial  anesthesia  of  asphyxia,  the  patient  will 
rapidly  revive  under  a  normal  supply  of  oxygen  though  his  suffering 
will  be  great.  Morpllin  should  therefore  be  given  as  quickly  as  possi- 
ble. In  the  management  of  the  excited  patient  upon  whom  an 
emergency  tracheotomy  is  performed  it  is  important  to  take  extra- 
ordinary care  to  prevent  further  excitement  or  further  pain.  Such 
a  patient  needs  rest  and  quiet  to  regain  normal  composure. 

Planned  Tracheotomy. — The  selection  of  the  position  for  a  trache- 
otomy depends  entirely  upon  the  condition  for  the  relief  of  which  the 
operation  is  to  be  performed.  Technically,  indeed,  two  considera- 
tions might  seem  to  influence  the  choice  of  the  position  of  the  opening. 
The  upper  portion  of  the  trachea  is  the  most  accessible,  but  at  this 
point  the  thyroid  renders  the  dissection  difficult:  in  the  lower  portion 
of  the  trachea  the  thyroid  does  not  interfere  with  the  dissection  but 
here  the  trachea  is  much  more  deeply  situated  in  the  neck.  In  a  con- 
trolled operation,  however,  neither  the  thyroid  above  nor  the  dee}) 
position  of  the  trachea  below  need  interfere  with  the  selection  of  that 
point  which  will  best  serve  the  purpose  of  the  tracheotomy.  A  trans- 


132 


OPKRATIVK  SUK<;KI;Y  OF  THK  NOSE,  THROAT,  AND  EAR. 


verse  incision  through  the  skin  leaves  the  best  ultimate  scar, — an 
important  consideration.  It  is  an  interesting  fact  that,  since  folds  and 
creases  are  normally  transverse  or  oblique,  a  vertical  scar  at  once 
fixes  the  attention,  while  a  greater  scar  even  is  unnoticed  if  it  be 
placed  obliquely  or  transversely.  A  transverse  skin  incision  presents 
but  little  more  technical  difficulty  than  an  ample  vertical  one.  A  con- 


FiK.   HU. 
Tracheotomy    under    local    anesthesia;    novocainixiiiK    the    skin, 

trolled  technic  so  easily  surmounts  this  obstacle  that  the  patient  should 
whenever  possible  he  triveii  the  advantage  of  the  transverse  incision. 
The  patient  is  first  placed  in  a  quiet  and  apathetic  condition  by 
means  of  a  moderate  dose  of  niorphin  or  of  niorphin  and  scopolamin. 
Xo  inhalation  anesthetic  is  used. 


LAKYXX,     1'IIAHYNX,     ri'l'F.lt     KSOl'l  I  A< ;  TS,    AND    TKACIIKA.  1 -i.5 

The  skin  and  subcutaneous  tissues  are  infiltrated  with  1  400  solu- 
tion of  novocain.  (Fig.  101.)  The  area  of  infiltration  is  put  under 
immediate  pressure  to  extend  the  anesthetic  field.  In  dividing  tin- 
tissues  sharp  dissection  only  is  used  and  the  field  is  kept  clear  and 
translucent  by  dividing  the  vessels  between  forceps  or,  when  this 
is  impossible,  by  clamping  them  immediately  after  their  division. 

The  wound  should  be  retracted  as  lightly  as  possible.  If  the  line 
of  incision  necessitates  the  division  of  the  thyroid  the  same  bloodless 
dissection  should  be  made.  If  the  lateral  lobes  of  the  thyroid  are 
fused  in  the  median  line  the  gland  may  be  grasped  in  forceps  on  each 
side  of  the  proposed  line  of  incision  and  divided.  (Fig.  10:!.)  After  com- 
plete division  of  the  thyroid  the  cut  margins  may  be  secured  against 


Fig.  1D2. 
Tracheotomy.     Incision   through   thyroid   gland  and   trachea. 

bleeding  by  the  insertion  of  button  hole  stitches  with  a  curved  needle. 
When  the  trachea  is  freely  exposed  it  is  carefully  infiltrated  with 
novocain — first,  the  superficial  layers,  then  gradually  and  slowly  the 
deeper  parts  of  the  tracheal  wall, — care  being  taken  not  to  allow  the 
needle  (which  should  be  a  fine  one)  to  penetrate  beyond  the  advanc- 
ing zone  of  infiltration.  The  needle  point  should  always  be  in 
anesthetized  tissue  so  that  the  tracheal  wall,  including  the  keenly  sen- 
sitive mucous  membrane,  may  be  anesthetized  without  causing  a  single 
cough.  The  addition  of  adrenalin  to  the  novocain  solution  makes 
possible  the  opening  of  the  trachea  without  pain  and  with  little  or  no 
oozing.  The  prevention  of  oozing  is  an  important  point,  first, 
because  blood  should  be  scrupulously  excluded  from  the  trachea 


OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 


as  a  protection  against  subsequent  infection;  and  second,  because  the 
trickling1  of  even  a  drop  of  blood  down  into  the  trachea  will  incite 
violent  coughing  and  the  strain  of  the  coughing  will  in  turn  increase 
the  oozing  because  of  the  increased  blood  pressure  caused  thereby. 
This  increased  oozing  again  causes  still  more  coughing  and  so  a 
vicious  circle  is  established.  Such  a  vicious  circle  cannot  well  be 
immediately  broken  by  sponging  the  blood  because  of  the  violent 
motion  of  the  coughing,  and  the  sponge  by  touching  the  anesthetized 
tissue  of  the  trachea  will  set  up  more  coughing  and  hence  defeat  its 
purpose.  If  in  spite  of  precautions  oozing  into  the  trachea  does  occur 


Fig.  103. 
Tracheotomy.     Novocainizing  the  trachea   from   within. 

one  can  only  wait  until  an  adjustment  takes  place  and  the  patient  be- 
comes quiet. 

In  dividing  the  trachea  the  operator  may  choose  between  a  trans- 
verse division  between  the  tracheal  rings,  or  a  vertical  division  passing 
through  the  rings.  The  transverse  incision  closes  more  readily  than 
the  vertical  but  it  does  not  offer  quite  so  free  an  opening.  Trache- 
otomies performed  for  temporary  purposes,  therefore,  should  be 
transverse;  but  for  the  long  continued  use  of  a  tracheal  tube — 
especially  it'  the  tube  is  to  be  handled  by  inexpert  hands,  the  vertical 
Incision  is  better. 

As  soon  as  the  trachea  is  opened  the  mucosa  should  be  anesthe- 
tized with  a  two  per  cent  solution  of  novocain.  Meanwhile  the  trachea 
is  held  open  with  such  an  instrument  as  a  small  single  hooked 
ienaciilum  to  provide  for  an  abundance  of  air.  (Fig.  10.').) 

The  teclmic  of  the   low  tracheotomy  is  the  same  as  that    for  the 


LARYNX,     I'HAUYXX,     1'IM'KK     KSOI'H  ACTS,    AM)    TKA< '  1 1  KA. 


1:55 


high  traclieotomy.  It  may  he  well  to  mention  two  rather  surprising 
facts,  however,  the  extraordinary  depth  of  the  trachea  low  in  a  thick 
neck,  a  depth  which  apparently  increases  in  a  restless  patient,  and 
the  astonishingly  extensive  excursion  of  the  trachea  in  the  act.  of 
coughing. 

In  this  connection  one  sees  a  remarkably  beautiful  dynamic 
adaptation  in  the  contraction  of  the  various  muscles  of  the  neck  to 
prevent  rupture  of  the  pleura.  Were  it  not  for  the  strong  protection 
offered  by  the  neck  muscles  the  pleura  at  the  apices  would  surely  be 
ruptured. 

Tracheal  Tube. — Among  the  many  types  of  t radical  tubes  the 
standard  curved  metal  cannula  consisting  of  an  inner  and  an  outer 
tube — gives  the  best  service.  (Fig.  104.) 

An  albolene  or  other  oil  spray  applied  to  the  trachea!  mucosa  is 
an  added  protection  against  secretions  and  against  too  much  drying 


Fig.  104. 
Tracheotomy.     After  the   operation. 

of  the  air  which  is  now  deprived  of  the  moisture  and  perhaps  warmth 
that  it  gains  in  passing  through  the  upper  air  passages  in  normal 
breathing.  At  all  events  the  liberal  use  of  an  oil  spray  not  only  adds 
to  the  comfort  of  the  patient  but  also  reduces  the  tendency  to  desicca- 
tion of  small  masses  of  mucus  in  the  neighborhood  of  the  trachea  1 
tube. 

After-care  of  the  Patient. — The  highly  efficient  after-care  of 
tracheotomy  patients  is  indeed  a  difficult  achievement.  There  is  an 
enormous  difference  between  the  efficiency  of  a  nurse  after  experience 
in  the  care  of  tracheotomy  cases  and  in  her  first  case.  It  is  well  to 
specialize  such  work.  For  the  proper  care  of  her  patient  the  nurse 


136  OPERATIVE    SURiiERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

requires  a  supply  of  feathers  trimmed  down  in  such  a  manner  that  the 
inner  tube  may  be  promptly  cleared  of  mucus  as  soon  as  the  peculiar 
mucus  noise  is  heard.  At  first  the  patient  tends  to  become  panicky 
v>:henever  any  mucus  obstruction  exists,  and  the  inexperienced  nurse 
may  share  the  patient's  apprehension, — surely  an  unhappy  atmos- 
phere. The  experienced  nurse  learns  to  manage  the  mucus  so  that 
there  is  only  an  occasional  necessity  to  remove  and  cleanse  the  tube. 

The  first  removals  of  the  tube  should  be  done  by  the  surgeon 
since  the  excitement  and  the  coughing  may  cause  a  certain  amount  of 
obstruction  which  may  throw  the  patient  into  a  panic,  ruder  these 
conditions  the  effort  to  replace  the  tube  may  increase  the  obstruction, 
cause  bleeding,  disturb  the  local  field  and  so  do  much  harm.  Tntil 
the  granulations  produce  a  living  mould  of  the  tube  and  thus  guide  it 
to  its  place  it  is  best  in  replacing  the  tube  to  use  a  pair  of  slender 
retractors — by  means  of  which  the  opening  in  the  trachea  may  be 
brought  into  view.  The  tracheotomy  tube  will  then  readily  drop  into 
place. 

The  air  of  the  patient's  room  should  be  kept  evenly  warm  and 
moist  and  may  be  medicated  by  vaporizing  pine  needle  oil.  The  moist 
air  and  a  piece  of  gau/e  moistened  with  salt  solution  placed  over  the 
"radical  tube  will  decrease  the  desiccation  of  the  secretions  about  the 
tube — and  will  maintain  a  higher  temperature  in  the  trachea.  The 
inhalation  of  cold  air  JUT  sc  is  not  harmful  as  the  ordinary  cold  air 
breathing  shows;  cold  air  may  produce  a  different  effect,  however, 
when  one  part  of  the  respiratory  tract  is  cool  and  the  remainder  re- 
mains warm  just  as  one  usually  catches  no  cold  when  entirely  naked 
hut  readily  takes  cold  if  there  is  only  a  partial  exposure  of  protected 
parts. 

The  t  radical  tube  and  the  entire  wound  should  be  protected  by  gau/e 
which  should  be  changed  frequently.  'Flic  patient  may  sit  or  lie  in 
any  desired  posture,  though  sitting  is  usually  preferable.  The  entire 
chest  and  neck  should  at  all  times  be  well  covered  with  oil  over  which 
a  pneumonia  jacket  is  placed,  ('old  drafts  in  the  room  are  especially 
to  be  avoided.  Nourishment  should  be  well  maintained.  It  is  most 
important  to  keep  the  wound  free  from  pus  accumulation  because  the 
inhalation  of  wound  discharges  is  a  distinct  danger.  If  there  is  no 
contraindication,  such  as  an  existing  obstruction,  it  is  well  occasionally 
to  n-niove  the  tube  for  a  time,  especially  if  the  patient  is  fretting 
about  the  irritation.  If  the  general  precautions  are  scrupulously 
ol»erved  the  iiTcat  danger  of  tracheotomy,  tracheobronehopiilmonary 
i  n  feet  ion  may  be  a  von  led. 

It    lia-    been    an    agreeable    surprise    to    observe    the    facility   \vith 


LAKYXX,     IMIAUYNX,     ri'l'KK     KSol'l  I  A< :  TS,    AM)    THAI '  1 1  KA.  l.'JT 

which  patients  care  for  their  1  radical  tubes  at'lci-  they  ha\'c  become 
adjusted.  It  is  done  as  a  matter  of  routine  and  with  the  precision 
accompanying  any  other  detail  of  the  daily  toilet.  The  author  has 
held  patients  retain  tracheotomy  tubes  for  as  lon^  as  twelve  years 
het'ore  the  opening  was  closed. 

Closure  of  a  Tracheotomy. — The  ultimate  closure  of  a  tracheotomy 
is  easily  accomplished.  The  entire  scar  is  bloodlessly  separated  from 
the  normal  tissues  surrounding  it  just  as  the  scar  is  dissected  out  in 
a  case  of  hernia  following  abdominal  drainage.  When  the  dissection 
has  reached  the  trachea!  wall,  the  infiltration  with  novocain  and 
adrenalin  is  most  carefully  extended  throughout  the  basal  attachment 
of  the  scai'  before  the  separation  of  the  scar  is  attempted.  After  the 
excision  of  the  scar  the  soft  parts  can  very  readily  be  brought  together 
into  their  normal  relation  in  the  median  line.  It  is  unnecessary  to 
suture  the  trachea  directly  because  on  the  release  of  the  scar  the  parts 
will  show  a  surprising  tendency  to  fall  together  even  after  many 
years  of  separation.  The  author  has  found  that  the  wound  heals  by 
first  intention  and  that  afterward  there  does  not  remain  a  dimple  or 
a  depression  even.  If  the  original  skin  incision  was  transverse  there 
will  soon  be  no  noticeable  scar  to  mark  the  place. 

The  cases  in  which  the  trachea  I  tubes  were  worn  longest  were 
those  in  which  there  were  larynx-filling  papillomata  in  little  children. 
In  three  such  cases  a  successful  issue  was  finally  reached — in  one 
after  twelve  years,  in  another  after  nine  years  and  in  the  third  after 
fourteen.  The  patients  were  inspected  at  various  intervals.  .Par- 
ticularly noteworthy  was  a  case  of  Dr.  \Y.  K.  Lincoln — in  which  after 
fourteen  years  the  larynx  was  found  to  be  free.  The  tracheal  tract 
was  then  closed.  During  this  time  the  larynx  grew  normally  though 
it  had  been  but  slightly  used. 

Cicatricial  Stenosis  of  the  Trachea. — Cicatricial  stenosis  of  the 
trachea  usually  follows  syphilitic  liberations,  decubitus  from  wearing 
intubation  tubes,  and  ulceration  from  other  causes. 

This  condition  presents  a  very  difficult  problem.  If  the  trachea 
be  opened  merely,  the  scar  dissected  out  as  neatly  as  possible,  and 
the  trachea  then  closed,  recurrence  is  quite  sure  to  occur.  Dissection 
followed  by  the  insertion  of  a  tube  gives  no  better  results.  The 
presence  of  the  tube  apparently  increases  the  reaction  which  is 
marked  by  the  formation  of  even  more  scar  tissue.  In  the  author's 
opinion  there  is  but  little  hope  in  any  method  except  in  resection  of 
the  trachea.  This  operation  offers  at  least  one  formidable  difficulty 
—the  surprisingly  great  elastic  retraction  of  the  trachea  toward  the 
lung,  which  exists  even  in  the  quiescent  state,  is  greatly  increased  bv 


138  OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

coughing.  This  retraction  of  course  throws  a  heavy  strain  on  the 
stitches  and  on  the  line  of  healing.  This  difficulty  can  be  met  by  the 
use  of  mattress  stitches  of  silver  wire  which  include  in  their  grasp  a 
ring  of  the  trachea  above  the  stenosis  and  one  below  it.  A  good 
closure  is  secured  by  inserting  three  such  silver  wire  mattress  stitches, 
one  on  each  lateral  side  of  the  esophagus  and  one  in  front,  leaving  the 
free  end  long  so  that  it  emerges  freely  from  the  wound.  By  twisting 
these  wire  sutures  the  apposition  of  the  trachea  is  readily  secured. 
This,  of  course,  can  succeed  only  when  the  trachea  is  quite  normal. 
If  the  rings  are  soft  or  the  tracheal  wall  edematous,  the  method  can- 
not succeed. 

In  one  of  the  author's  cases  the  tracheal  wall  was  in  such  poor  con- 
dition that  the  sutures  could  not  hold  and  it  was  necessary  in  the  end 
to  resort  to  a  permanent  tracheal  tube.  Fortunately  there  are  not 
many  of  these  cases. 

Surgery  of  the  Larynx. 

Laryngectomy  for  Intrinsic  Cancer. — The  legitimacy  of  opera- 
tion upon  any  part  of  the  body,  especially  those  parts  the  damage  of 
which  may  cause  immediate  danger  to  life,  depends  upon  the  answers 
which  can  be  given  to  three  vital  questions:  Will  the  operation  result 
in  the  cure  of  the  disease?  Can  the  risks  be  overcome?  What  will  he 
the  extent  of  permanent  disability?  So  uncertain  until  very  recent 
years  have  been  the  answers  to  these  questions  as  applied  to  laryn- 
gectomy  for  cancer,  that  it  is  not  strange  that  the  operation  is  one 
of  the  most  recent  developments  in  surgical  history,  having  been  first 
performed  by  Bill  roth  in  1S74. 

Even  after  surgeons  had  become  convinced  of  the  possibility  of 
the  cure  of  intrinsic  laryngeai  cancer  by  this  means  it  was,  and  is  still, 
most  difficult  to  persuade  patients  to  submit  to  it — the  instinctive  objec- 
tion to  deep  throat  operations  being  the  natural  outcome  of  the  expe- 
riences of  the  far  distant  past  when  the  throat  was  the  point  of  attack 
in  oiii1  carnivorous  evolutionary  ancestors,  and  it  being  still  the  part 
most  liable  to  danger  in  hand-to-hand  conflict. 

Does  laryngectomy  for  cancer  result  in  a  cure  of  the  disease? 
I  pon  our  answer  to  this  depends  the  need  for  considering  the  other 
two  questions.  We  still  accept  Krishaber's  classification  of  laryngeai 
cancer  as  intrinsic  and  extrinsic.  As  the  term  implies,  intrinsic  laryn- 
geal  cancer  starts  within  the  larynx  itself  in  the  vocal  cords,  the  ven- 
tricular bands  or  the  parts  below;  while  the  extrinsic  form  starts  in 
the  epiglottis,  the  arytcnoids  or  other  parts  outside  the  larynx  proper. 
Intrinsic  cancer,  then,  is  contained  within  a  hyaline  cartilage  box,  and 


LAKY.NX,     IMIAHYNX,     CIM'KK     KSOl'IIAOTS,    AND    TI!A< '  1 1  KA.  139 

is  in  large  measure  cut  off  from  Hie  possibility  of  lymphatic  involve- 
ments; while  the  extrinsic  form  grows  rapidly  and  can  easily  and  early 
extend  through  the  lymph  channels. 

Early  diagnosis  and  removal  is  the  keynote  of  safety  in  cancer- 
ous growths  anywhere,  and  laryngcal  cancer  makes  itself  known  almost 
at  once,  since  from  its  very  beginning  the  probability  of  its  presence 
becomes  evident  in  the  persistent  hoarse  voice  of  the  patient.  We  may 
say,  then,  that  intrinsic  laryngeal  cancer  exists,  as  it  were,  in  a  safe 
deposit  box.  It  early  announces  its  presence  and  has  but  fe«ble  power 
of  extensive  invasion  or  of  metastasis.  We  conclude,  therefore,  that 
this  form  of  cancer  of  the  larynx  is  curable  by  excision.  Kxtrinsic 
cancel1,  on  the  other  hand,  is  rapidly  fatal,  and  operation  for  its  relief 
is  at  best  but  a  desperate  remedy. 

What  is  the  surgical  risk:'  The  author  has  performed  twenty- 
seven  laryngectomies  for  cancer  with  two  operative  fatalities;  one 
deatli  resulting  from  mediastinal  abscess,  the  other  from  necrosis  of 
the  trachea  with  a  consequent  septic  pneumonia.  This  makes  a  mor- 
tality rate  of  seven  plus  per  cent,  a  rate  which  compares  favorably  witli 
that  of  excisions  for  cancer  of  the  tongue,  of  the  stomach,  and  of  the 
rectum. 

What  is  the  permanent  disability  of  the  patient?  Those  princi- 
pally feared  are  impairment  of  speech,  disfigurement,  and  a  predispo- 
sition to  pulmonary  diseases  and  accidents.  As  to  speech  impairment, 
all  patients  acquire  a  Imccal  whisper  which  serves  the  purpose  of 
speech  remarkably  well.  One  of  the  author's  patients  is  at  the  head 
of  a  large  industrial  corporation;  another  is  a  judge;  another  is  fore- 
man in  a  public  works  department;  another  became  a  popular  barber: 
still  another  is  managing  a  small  coal  sales  agency;  one  housewife  ap- 
parently gets  on  well  enough;  and  a  farmer  has  managed  his  Hocks  and 
his  teams  in  silence.  The  speech  defect,  to  be  sure,  is  great,  but  it  can 
be  compensated  for  to  a  remarkable  degree  by  the  development  of  the 
buccal  whisper,  the  use  of  gestures  and  other  forms  of  primitive  lan- 
guage, and  by  the  adaptation  of  those  individuals  who  come  into  daily 
contact  with  the  patient. 

The  disfigurement  may  be  well  covered  by  wearing  various  kinds 
of  cravats  or  neckwear  arranged  in  such  a  manner  as  to  allow  free 
breathing,  and  at  the  same  time  to  diminish  the  sibilant  sounds  of  the 
changing  air  currents. 

As  to  the  predisposition  to  accident  and  disease,  to  the  author's 
knowledge  there  has  been  no  instance  of  a  foreign  body  in  the  respira- 
tory tract  of  any  of  his  laryngectomized  patients,  nor  has  there  been  a 
single  case  of  pneumonia.  Not  only  have  his  patients  shown  no  ten- 


140  OPERATIVE    STRHERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

clency  to  pneumonia  and  bronchitis,  but  they  have    boon    remarkably 
free  from  nasal  colds. 

We  may  conclude,  then,  in  answer  to  onr  third  question,  that 
though  the  disability  resulting  from  laryngectomy  is  great  yet  it  is 
fairly  well  compensated  for. 

Some  years  ago  the  author  made  an  interesting  study  of  the  laryn- 
gectomies  reported  in  the  medical  press  from  1874  to  1901.  A  summary 
of  the  statistics  gives  significant  results.  From  1874  to  1876,  1:2  lar 
yngectomies  for  carcinoma  were  reported  with  one  ultimate  cure,  mak- 
ing the  percentage  of  ultimate  cures  8.88.  From  1876  to  1886,  108  lar- 
yngectomies,  '21  ultimate  cures,  percentage  of  ultimate  cures  19.44. 
From  1886  to  1896,  15(5  laryngectomies,  49  cures,  percentage  of  cures 
•211. 81'.  From  1896  to  1901,  :!()  laryngectomies,  '20  cures,  percentage  of 
cures  66.67.  The  causes  of  death  as  reported  are  those  with  which  we 
still  are  contending,  but  which  improved  technic  lias  helped  us  in  large 
measure  to  meet.  Indeed,  the  figures  just  given  show  the  increasinLi; 
confidence  of  surgeons  and  patients  in  operative  relief  for  this  distress- 
ing disease,  a  confidence  well  supported  by  the  rapidly  decreasing 
mortality  rate. 

Anesthetic  in  Laryngectomy. — Before  proceeding  to  the  detailed 
technic  of  laryngectomy,  some  special  statement  should  be  made 
regarding  the  manner  of  administering  the  anesthetic.  It  should  be 
borne  in  mind  that  the  administration  of  the  anesthetic  should  be  so 
planned  that  the  operator  may  be  unhampered  in  his  technic.  that  the 
anesthetist  may  give  an  even  and  safe  anesthetic,  and  that  there  may 
be  no  inhalation  of  blood,  while  the  choice  of  the  anesthetic  itself  is  a 
most  important  factor.  Our  general  anesthetic  of  choice  is  nitrous 
oxid-oxygen.  The  patient  already — it  is  presumed— in  fear  of  the 
possible  suffocating  results  of  a  laryngeal  operation,  takes  this  anes- 
thetic without  the  terrifying  suffocating  symptoms  caused  by  ether, 
and  is  quickly  under  its  influence  without  a  struggle.  \Ve  have  proved 
also  by  laboratory  investigations  that  whil<>  nitrous  oxid  does  not 
alter  the  immunity  of  the  patient,  other  on  the  other  hand  tends  to 
impair  the  immunity.  Since  nitrous  oxid-oxygen,  however,  should  be 
U'iven  by  the  trained  anesthetist  only,  the  following  technic  is  equally 
applicable  to  the  administration  of  ether.  In  our  discussion  of  niedi- 
astinitis  wo  have  described  the  preliminary  tracheotomy  by  means  of 
which  the  trachea  has  become  firmly  fixed  in  its  position.  (Fig.  10.").) 
At  the  time  of  operation  the  tracheotomy  lube  is  removed  and  a  well- 
lubricated  snug-fitting  rubber  tubing  a  foot  or  more  long  is  slowly  and 
carefully  .-lipped  into  the  trachea.  The  rubber  tubing  being  slightly 
larger  than  the  trachea,  the  latter  is  dilated  and  the  rubber 'tube  com 


LAHVNX,     IMIAKYNX,     I'l'l'MI!     KS<  tl'l  I  A<  i  I 'S,    AM)    THACIIKA. 


141 


pressed,  so  that  a  fluid-tight  fit  results.  By  this  moans,  the  entrance  of 
any  blood  into  the  respiratory  tract  is  prevented.  (Fig.  10(i.)  The 
long  piece  of  rubber  tubing  may  then  be  attached  to  the  nit  rous- oxid- 
oxgyen  apparatus,  or  it  may  be  joined  to  a  special  apparatus  consist- 
in  i>'  of  a  funnel  covered  with  gau/e  upon  which  ether  may  be  dropped. 
By  this  arrangement  the  anesthetist  is  at  a  distance  from  the  field  of 
operation  and  is  unhampered  by  the  operator,  while  the  operator  on 


Fig-,   in."",. 
Laryngectomy.     Preliminary  tracheotomy  with  iodot'orm  gauze  packing. 

his  side  is  unhampered  by  the  anesthetist.  There  results  an  even  anes- 
thesia and  the  best  opportunity  for  a  well  controlled  operation. 

To  prevent  nocuous  impulses  from  the  field  of  operation  from 
reaching-  the  brain,  and  as  a  protection  against  the  excitation  of  special 
reflexes  through  the  mechanical  stimulation  of  the  trunk  or  terminals 
of  the  superior  laryngeal  nerves,  novocain  is  used  as  a  local  anesthetic. 
The  manner  of  its  administration  will  be  given  in  the  description  of 
the  operative  technic. 

Technic  of  Laryngectomy. — First  the  skin  is  thoroughly  infiltrated 


U'2 


OPERATIVE    SUHCKHV    OF    THE    NOSE,    THROAT,    AND    EAR. 


with  novocain  along  the  median  line  from  a  point  ahove  tlie  hyoid  l>one 
to  the  traclieotomy  opening.  The  tissues  are  divided  down  to  the  box 
of  the  larynx,  the  divisions  of  the  platysma  and  of  the  other  soft  parts 
being1  preceded  also  by  novocain  infiltration.  The  dissection  is  then 


Cut  surface  covered 
\vith  granulations. 


Fig.   10G. 

Laryngectoniy.      Five    days    after    preliminary     traclieotomy.      Arrange- 
ment, of  tul)e  for  anesthesia. 

carried  down  along-  the  lateral  aspects  of  the  larynx  until  the  larynx  is 
completely  freed.  If  there  is  hick  of  free  working  space  at  the  upper 
end  a  lateral  incision  is  made  parallel  with  the  hyoid.  The  thyrohyoid 
muscles  ahove  and  the  sternotliyroid  muscles  below  are  severed.  So 
far  as  its  muscular  attachments  are  concerned,  the  larynx  is  now  com- 
pletely mobilized.  If  the  laryngoKcopic  examination  has  fixed  accu- 


LARYNX,    LMIAKYNX,     UIM'KH    KSO1M I  AC  I'S,    AN*  I)    TKACIIKA. 


14:5 


ratoly  the  limits  of  the  neoplasm,  the  level  of  the  division  of  the  larynx 
may  bo  predetermined,  and  the  next  step  will  he  the  division  of  the 
trachea  or  the  cricoid  at  a  level  free  from  disease.  Before  this  last 
division  is  made,  however,  iiovocain  is  infiltrated  into  the  nmcosa 
throughout  the  entire  length  of  the  proposed  division.  By  this  means 
the  terminals  of  the  superior  laryngeal  nerves  are  completely  blocked 
and  the  mucosa  may  be  divided  and  the  larynx  opened  without  causing 
a  change  in  the  respiration  or  the  circulation.  If  the  patient  is  old 
and  the  cartilage  is  ossified  it  is  necessary  to  exert  the  greatest  pn-- 


Fig.   107. 
Laryngectomy.     Separation   of  the  larynx   from  the  esophagus. 

caution  in  dividing  the  larynx  in  order  that  the  esophagus  may  not 
be  injured.  The  divided  end  of  the  larynx  is  next  raised  up  and  the 
attachment  between  the  larynx  and  the  esophagus  is  divided  with 
knife  or  scissors.  (Fig.  107.)  In  a  short,  thick  neck  the  wings  of  the 
larynx  which  extend  down  laterally  to  protect  each  side  of  the 
esophagus,  are  divided  with  scissors.  The  dissection  is  then  carried 
upward  until  the  upper  end  of  the  larynx  is  reached,  where  its  pos- 
terior wall  becomes  fused  with  the  anterior  wall  of  the  pharynx.  The 
upper  end  of  the  larynx  is  then  cut  free,  the  larger  arteries  being 
severed  at  the  verv  last.  I  lemostasis  must  be  most  tliorouu'hlv  ob- 


144 


OPERATIVE    STRdERY    OF    THE    NOSE,    THROAT,    AND    EAR. 


served  throughout  the  operation.  If  the  cancer  is  intrinsic  the 
lymphatic  glands  which  drain  the  diseased  zone  should  be  carefully 
removed  with  the  larynx  itself. 

Two  important  questions  now  arise  regarding  the  manner  of  deal- 
ing with  the  wound:  (1)  What  shall  be  done  with  the  end  of  the 
trachea.'  and  ('2)  Shall  the  entire  wound  of  the  neck  be  closed?  As 
to  the  trachea,  there  are  two  alternatives:  It  may  be  freed  sufficiently 
to  bring  it  forward  and  stitch  it  to  the  skin,  or  it  may  be  left  where 
it  lies,  excepting  at  its  very  upper  end,  which  may  be  bent  forward 


Fig.   108. 
Laryngortoiny.     Closure  of  pliaryngral  opening. 

and  sewed  to  (laps  of  skin  brought  down  from  each  side.  The  advan- 
tage of  the  first  method  is  that  by  this  means  the  trachea  is  protected 
from  the  inhalation  of  wound  secretion.  The  disadvantage  is  the  very 
definite-  possibility  that  the  loss  of  blood  supply  may  result  in 
gan.uTcnc  of  the  trachea.  This  did  occur  in  one  of  the  author's  cases. 
The  objection  to  leaving  the  trachea  in  its  natural  bed  and  transplant- 


IMIAKYXX,     I'lM'KH     KS<  )IM  I  ,\<  i  I' S,    AND    TUACIIKA. 


140 


ing  to  it  the  skin  flaps  is  the  fact  that  wound  secretion  will  almost 
certainly  enter  it.  By  giving  the  wound  adequate  care,  however,  this 
danger  may  he  avoided. 

As  to  the  care  of  the  rest  of  the  wound,  the  author's  best  pro- 
cedure has  been  to  suture  the  opening  in  tin;  pharynx  and  (Fig.  10*), 
if  possible,  to  roonforee  this  suture  by  drawing  other  soft  parts  togct her 
over  it.  The  rest  of  the  field  is  left  open,  being  packed  lightly  with 
iodoform  gauze.  (Fig.  10!).)  With  such  a  wide  open  wound  the 
secretions  may  bo  easily  controlled  and  prevented  from  entering  the 
trachea.  The  patient  should  be  sustained  by  the  fullest  diet  he  can 


Fig.  Id!). 
Laryngectomy.     Closure  of   wound   with    iodoform   gauze   packing. 

be  made  to  take,  and  by  most  careful  nursing.  The  sutures  in  the 
pharynx  may  not  hold,  but  the  formidable-looking  wound  will  close 
very  readily  by  granulation  and  contraction. 

Laryngectomy  is  followed  usually  by  a  brisk  local  reaction:  but 
since  the  mediastinum  has  been  protected  by  the  previous  gauze  pack- 
ing, and  the  bronchopulnionary  tract  has  been  given  a  special  defense 
by  the  preliminary  tracheotomy,  the  patient  is  well  equipped  to  meet 
the  new  condition. 

In  the  author's  twenty-seven  laryngectomies  there  were  two 
deaths,  and  these  two  were  apparently  the  most  promising  cases  of 
all.  The  prognosis  in  these  cases  seemed  so  favorable  that  the  author 


146  OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

ventured  to  discard  the  full  preliminary  preparations.  In  one  case 
no  preliminary  protective  operation  of  any  kind  was  made  and  the 
patient  died  at  the  end  of  five  weeks  with  mediastinal  abscess.  In  the 
other  case  a  preliminary  gauze  packing  was  placed  in  the  neck  around 
the  trachea,  but  no  preliminary  tracheotomy  was  performed.  In  this 
case  the  isolated  upper  end  of  the  trachea  was  brought  forward  to  the 
skin  and  anchored.  The  entire  isolated  portion  necrosed,  as  did  also 
a  portion  of  the  trachea  beyond  the  isolated  part.  As  a  result  pus  was 
inhaled  into  the  respiratory  tract  below  the  level  of  the  sternum.  An 
autopsy  showed  no  pneumonia  and  no  mediastinitis,  but  a  septic 
tracheitis  and  bronchitis.  Death  was  the  result  of  local  absorption, 
and  of  absorption  from  the  trachea  and  from  the  bronchial  mucosa. 
This  case  demonstrated  most  conclusively  the  efficiency  of  the  granu- 
lation barrier  which  is  created  by  a  preliminary  iodoform  packing. 
Had  a  preliminary  tracheotomy  been  made,  or  had  the  trachea  been 
allowed  to  remain  in  its  bed,  the  patient  would  surely  have  recovered. 

In  sixteen  of  these  twenty-seven  laryngectomies  for  cancer  the 
laryngeal  box  was  so  choked  with  the  growth  that  tracheotomy  was 
required  to  prevent  suffocation.  Most  of  the  author's  patients  gave 
a  long  history  of  hoarseness  followed  by  gradual,  though  intermittent 
obstruction  to  respiration.  In  two  cases,  there  was  associated  lues. 
One  of  these  last  two  cases  illustrated  well  the  clinical  difficulty  of 
diagnosis.  The  lesion  was  first  diagnosed  correctly  as  luetic,  and 
under  a  course  of  treatment  the  greater  part  of  the  growth  disappeared. 
The  residual  growth,  however,  showed  a  progressive  tendency,  and 
was  later  diagnosed  as  cancer.  Laryngectomy  was  performed  and  the 
patient  is  now  alive  and  well,  more  than  three  years  since  his  opera- 
tion. The  special  lesson  from  this  case  is  that  cancer  of  the  larynx, 
like  cancer  of  the  tongue,  may  follow  local  luetic  lesions.  There  is 
danger,  therefore,  that  the  hope  of  a  luetic  cure  may  defer  too  long 
the  laryngectomy  which  is  the  only  chance  for  the  cure  of  the  cancer. 

Extrinsic  Cancer  of  the  Larynx. — As  already  stated  extrinsic 
cancer  of  the  larynx  presents  a  different  and  a  more  desperate  problem 
than  does  intrinsic  cancel'.  Extrinsic  cancer  is  more  difficult  to  attack 
on  account  of  its  position;  it  is  disseminated  earlier  and  more  widely 
on  account  of  the  greater  muscular  activity  of  the  parts  involved. 
Extrinsic  cancer  of  the  larynx  is  however  more  accessible  than  cancer 
of  the  tonsil  or  cancer  of  the  pharynx.  The  same  considerations  apply 
to  eMiicer  of  the  base  of  the  tongue. 

In  attacking  cancel1  here  a  preliminary  tracheotomy  is  essential, 
wide  neck  incisions  are  made,  the  cancel1  is  exposed  most  cautiously 
and  is  thoroughly  thermocaiiteri/ed.  In  the  further  dissection  great 


LAKYXX,    I'llAHVNX,     Tl'I'KK    KSOIM I  A< :  fS,    AM)    TKACIIKA.  147 

care  must  bo  exorcised  not  to  disturb  tlio  osoliar.  After  complete  and 
wide  excision  of  tlie  cancel'  the  wound  should  be  left  wide  open  for 
the  free  use  of  the  X-ray. 

In  one  instance  the  author  excised  the  base  of  the  tongue,  the 
pillars  of  the  pharynx,  the  pharynx  itself,  the  entire  larynx,  the  hyoid, 
—in  short  all  of  the  tissues  lying  between  the  juncture  of  the  posterior 
and  the  middle  third  of  the  tongue,  the  upper  ring  of  the  trachea  and 
the  upper  end  of  the  esophagus,  leaving  but  a  slight  covering  of  the 
vertebra4.  This  enormous  wound  looked  hopeless  for  a  long  time— 
during  which  the  X-ray  was  used  freely — but  finally  closed  completely. 

About  four  years  later  metastasis  developed  in  one  of  the  sub- 
maxillary  lymphatic  glands.  When  the  author  saw  it,  this  inland  was 
quite  largo,  was  inHamed,  hugged  the  jaw  closely  and  involved  the 
swollen  reddened  skin  covering  it.  Again  a  wide  excision  was  inado, 
so  extensive  that  the  wound  could  not  have  been  closed  had  the  author 
so  desired.  The  X-ray  was  used  freely  during  the  process  of  healing. 
The  lower  jaw  was  so  closely  linked  by  the  cancel1  that  about  one- 
third  of  the  jaw  was  sawed  off  longitudinally — the  sawed  fragment  of 
bone  coming1  off  with  the  rest  of  the  cancer.  In  due  time  the  wound 
was  skin  grafted  and  closed.  It  has  been  over  five  years  since  this 
last  operation  and  nine  years  since  the  first.  The  patient  is  now  at 
work.  He  speaks  with  a  sort  of  buccal  whisper, — is  able  to  swallow, 
to  drink  and  to  smoke  with  ease  and  comfort. 

This  case  taught  the  author  that  no  one  can  tell  when  a  case  is 
hopeless — for  surely  this  patient  seemed  to  be  in  a  hopeless  condition. 
The  repair  of  the  mutilations  produced  by  this  operation  in  which  so 
many  important  structures  were  removed  and  the  consequent  recovery 
have  been  a  source  of  encouragement  and  inspiration  ever  since. 

In  another  case  of  extrinsic  cancer  the  operation  in  a  local  field 
was  not  so  extensive  but  the  lymphatic  involvement  was  much  greater. 
In  this  case  the  growth  had  so  filled  the  larynx  that  the  obstruction 
had  caused  asphyxia,  as  a  result  of  which  the  patient  had  fallen  upon 
the  street.  An  emergency  tracheotomy  was  performed,  at  which  time 
one  of  the  lymphatic  glands  was  removed  for  diagnosis.  At  the  later 
operation  the  excision  was  carried  laterally  so  as  to  include  the 
lymphatic  gland-bearing  tissue  on  both  sides,  all  of  which  was  removed 
en  bloc  with  the  larynx  and  the  base  of  the  tongue.  The  patient  is 
well  and  hale  seventeen  years  after  the  operation. 

Stenosis  of  the  Larynx. — Stenosis  of  the  larynx  may  be  due  to 
intubations — now  infrequently  done — or  to  ulcerations  which  are 
usually  syphilitic.  Like  stenosis  of  the  trachea — already  described 
— stenosis  of  the  larvnx  is  an  exceedingly  formidable  condition. 


148  OPERATIVE  SURUERY  OF  THE  NOSE,  THROAT,  AND  EAR. 

The  author  has  attempted  to  open  the  larynx  by  splitting  it 
vertically,  dissecting  out  the  scar  and  then  resuturing  the  incision, 
but  the  stenosis  recurred  so  promptly  that  the  patient  \vas  denied  the 
comfort  of  a  goodly  respite  even. 

In  another  instance  the  author  did  a  hemilaryngectomy  in  the 
hope  that  the  larynx  might  adapt  itself  as  it  may  do  in  hemilaryngec- 
tomy  for  cancer — but  this  did  not  afford  a  permanent  air  space. 

In  another  case  the  larynx  was  opened  wide,  the  scar  was  com- 
pletely dissected  out  and  an  attempt  was  made  to  cover  the  raw  area 
immediately  with  large  and  accurately  placed  skin  grafts.  The 
respiratory  tract  and  the  grafts  as  well  were1  protected  by  a  trache- 
otomy. .Despite  the  utmost  care  the  grafts  did  not  grow.  For  a  time 
they  did  well,  but  the  patient  was  a  child  only  four  years  old  and  hard 
to  control.  The  author  gained  the  impression  however  that  were  it 
an  adult  case  and  the  skin  grafts  autodermic  they  might  have  held. 
Even  then,  however,  one  could  not  be  certain  that  the  scar  might  not 
again  contract.  In  a  child  with  stenosis  of  the  ericoid  referred  to  the 
author  by  Dr.  W.  B.  Chamberlain,  an  attempt  was  made  to  remedy  the 
stricture  by  resecting  the  lower  end  of  the  ericoid  and  suturing  the 
trachea  and  the  divided  ericoid  together  by  means  of  silver  wire. 
The  resection  of  the  strictured  ericoid  was  easily  accomplished  but  as 
the  trachea  was  so  much  smaller  it  was  difficult  to  bring  it  into 
precise  tubular  apposition.  Although  a  union  was  secured  the 
stenosis  was  not  relieved  and  the  author  was  obliged  to  resort  to  a 
permanent  trachea!  tube.  With  our  present  means  the  author  is 
unable  to  see  much  hope  in  operations  for  strictures  of  the  larynx 
resulting  from  massive  scar  tissue  firmly  fixed  to  the  box  of  the  larynx. 
In  one  case  the  use  of  thiosinamin  was  added  to  the  operative  pro- 
cedure hut  apparently  its  influence  was  nil. 

Surgery  of  the  Pharynx  and  Esophagus. 

Cancer  of  the  Pharynx  and  Esophagus. — Hitherto  cancel-  of  the 
esophagus  and  of  the  pharynx  has  not  been  attacked  as  successfully 
as  cancer  in  many  other  parts  of  the  body.  When  dealing  surgically 
with  cancel1  in  these  regions  it  is  important  to  bear  in  mind  that  if 
cancer  cells  become  lodged  iii  the  fresh  wound  they  are  not  only  likely 
to  grow,  but  to  grow  with  oven  greater  vigor  than  in  the  original 
lesion.  There  is  not  an  abundance  of  experimental  evidence  to  support 
this  statement  but  ample  clinical  proof  is  not  lacking.  The  experi- 
mental evidence  that  is  especially  pertinent  is  the  following:  It  a 
piece  of  cancer  tissue  from  a  dog  is  rubbed  on  an  abraded  surface  of 
the  skin  of  another  dog  a  cancer  is  likely  to  develop  from  the  cells 
which  became  detached  and  lodged  on  the  denuded  surface. 


LARVNX,   riiAin.xx,    ri'i'Ki;   KSOIMI AIM'S,  AND  TUACIIKA.  141* 

In  operations  for  cancer  anywhere  if  the  field  is  not  protected  the 
entire  raw  surface  area  will  be  sown  with  cancer  cells  and  a  rich 
growth  of  cancer  will  spring  up  over  the  entire  wound  surface-,  will 
grow  furiously  and  usually  will  cause  the  death  of  the  patient  in  less 
time  than  would  the  original  growth  had  it  been  left  unmolested. 
This  is  perhaps  the  most  important  point  to  be  considered  in  the 
treatment  of  cancer  of  the  pharynx,  the  tonsil,  tin-  pillars  or  the  rima 
glottidis.  The  operation  is  technically  beset  with  difficulties  but  no 
instrument,  no  finger,  no  sponge,  that  has  touched  the  cancer  surface, 
should  be  used  again,  nor  should  they  touch  anything  else  that  may 
be  used  in  the  operation.  The  operation  should  not  be  undertaken 
if  its  result  is  to  he  no  more  than  the  implantation  of  a  new  cancel- 
that  may  extend  even  farther  than  the  original  growth.  The  only 
means  by  which  the  reimplantat  ion  of  cancer  cells  may  be  prevented 
is  hy  the  immediate  and  complete  destruction  of  the  original  growth 
by  thermo-cauterization.  Tare  must  then  he  taken  to  prevent  the 
dislodgment  of  the  eschar — and  even  after  these  precautions  have 
been  taken  it  is  hest  to  follow  the  operation  by  the  use  of  the  X-ray  if 
the  field  is  accessible.  It  is  wise  also  to  make  a  very  wide  excision 
of  the  growth,  and  to  remove  all  the  lymphatic  nodes  which  drain  the 
involved  area.  In  serious  risks  it  is  best  to  perform  the  operation  in 
two  stages,  first  excising  the  local  field,  and  then  after  ten  days  or  more 
removing  the  lymphatic  bearing  tissue  of  the  neck  by  a  block  excision. 
If  the  growth  is  located  in  the  tonsil  or  the  pillars  it  is  possible  to  give 
the  anesthetic  and  to  prevent  the  inhalation  of  blood  either  by  passing 
tubes  through  the  pharynx  and  packing  them  with  gauze,  or  by  the 
intratracheal  insufflation  method  of  Aleltzer  and  Auer.  If  the  cancer 
is  still  lower  down,  it  is  hest  to  make  a  preliminary  tracheotomy  and 
introduce  as  large  a  rubber  tube  as  the  trachea  will  hold,  thus  prevent- 
ing the  inhalation  of  blood.  In  operations  on  the  tonsil  the  application 
of  a  CYile  clamp  on  the  external  carotid  artery  will  minimize  the 
hemorrhage. 

Excision  of  the  Tonsil  for  Cancer. — Bearing  in  mind  the  general 
precautions  stated  above,  the  excision  of  the  tonsils  for  cancer  is  per- 
formed in  the  following  manner: 

1.  A  tube  for  the  administration    of    the    anesthetic    is    passed 
through  the  pharynx  and  held  by  gauze  packing. 

2.  All  of  the  visible  growth   is  completely  destroyed   by  thermo- 
cauterization. 

:>.  The  lymphatic  glands  which  drain  the  tonsil  are  excised 
en  bloc  through  a  wide  neck  incision. 

4.     The  external  carotid  is  closed  by  means  of  the  Crile  clamp. 


150  OPERATIVE  SUR<;ERY  OF  THE  XOSE,  THROAT,  AXD  EAR. 

5.  If  more  room  is  needed  the  ramus  of  the  jaw  is  divided. 

6.  With  the  fingers  of  one  hand  inside  the  throat  a  wide  dissec- 
tion is  made  of  the  base  of  the  growth,  extreme  care  being  taken  to 
leave  undisturbed  the   eschar   surface.      Internal   as   well   as   external 
dissection  should  be  used  if  necessary. 

7.  The  vessels  are  closed  carefully.     A  curved  needle  and  catgut 
being  used  if  necessary  to  control  oozing  in  the  mouth. 

S.     The  clamp  is  removed  from  the  external  carotid. 

9.  A  Lane  plate  is  applied  to  the  divided  ramus.     The  plate  may 
cause  suppuration,  but  it  will  hold  the  bone  in  place  until  union  has 
been  secured. 

10.  The  wound  is  immediately  exposed  to  X-rays  if  the  patient's 
condition  warrants  it. 

11.  The    wound    is    packed    with    iodoform    gauze — the    external 
wound  being  partially  closed. 

Cancer  of  the  Pillars. — Tn  operations  below  the  tonsil  the  best 
procedure  is  to  perform  a  tracheotomy  and  then  to  open  the  pharynx 
freely  by  means  of  an  ample  incision  just  above  the  hyoid.  The  same 
procedures  as  those  described  in  the  operation  for  cancer  of  the  tonsil 
are  applicable  here  except  that  the  wound  in  the  neck,  by  means  of 
which  the  exposure  is  made,  is  closed  at  once,  and  it  is  not  necessary 
to  apply  temporary  clamps  upon  the  carotid.  It  is  well  to  allow  the 
tracheotomy  tube  to  remain  until  the  pharyngeal  wound  is  well  healed. 

Stenosis  of  the  Pharynx. — The  discouraging  results  of  operative 
procedures  for  the  relief  of  stenosis  of  the  pharynx  are  well  illustrated 
by  the  following  history  of  one  of  the  author's  cases.  This  patient 
has  already  undergone  twenty-four  operations  of  various  kinds  in- 
cluding all  the  intrapharyngeal  methods.  The  author  resolved  to 
make  a  wide  excision  of  every  vestige  of  the  stricture.  A  preliminary 
tracheotomy  was  made,  ten  days  after  which  the  principal  operation 
was  pel-formed.  An  incision  was  made  around  the  anterior  half  of 
the  neck  through  the  skin,  platysma  and  fascia.  The  pharynx  was 
then  opened.  With  one  hand  inside  the  pharynx  the  dissection  above 
and  below  the  stricture  could  be  accurately  guided  so  easily  that  the 
author  was  able  to  make  an  annular  resection  including  the  entire  area 
of  the  scar.  By  means  of  a  long  needle  with  an  eye  near  the  point 
mattress  stitches  were  inserted  into  the  opposing  pharyngeal  walls, 
thus  bringing  together  this  enormous  opening  in  the  throat.  The 
wound  healed  splendidly,  but  after  some  months  the  stricture  recurred. 

The  author  then  planned  another  type  of  operation.  A  long 
perineal  needle  with  an  eye  near  the  point,  threaded  with  heavy  silver 
wire,  was  passed  through  the  skin  of  the  side  of  the  neck  and  through 


I.AKYNX,     1M1AKYXX,     I'IM'KK    KSOPI I  A< ;  t'S,    AM)    TKACIIKA.  1  •">  1 

all  the  soft  parts  down  to  the  base  of  the  stricture-.  Tin;  base  of  the 
stricture  was  then  pierced,  the  needle  passing  into  the  month.  The 
silver  wire  was  then  detached  from  the  eye  and  the  needle  was  with- 
drawn until  the  point  was  once  more  external  to  the  base  of  the 
stricture,  and  was  then  passed  through  the  small  opening  in  the 
center  of  the  pharynx.  The  free  end  of  the  silver  was  again  threaded 
into  the  eye  of  the  needle  and  the  needle  was  withdrawn.  In  this 
manner  one  side  of  the  scar  was  grasped  by  the  loop  of  heavy  silver 
wire.  Another  wire  was  similarly  inserted  into  the  opposite  side  and 
both  wires  were  tightly  twisted.  The  purpose  of  this  procedure  was 
to  form  a  mucous-membranc-covered  fistula  analogous  to  the  skin 
fistula  one  makes  when  operating  for  web  finder.  This  was  faithfully 
tried  but  unfortunately  the  wake  of  the  wires  filled  as  fast  as  they  cut 
their  way  out.  The  author  then  abandoned  further  efforts  and  made 
an  esophagostomy,  which  appeared  to  be  the  only  possible  means  of 
relief. 

Esophagostomy. — Like  tracheotomy  and  enterostomy,  esophagos- 
tomy  may  be  permanent,  or  it  may  be  used  for  temporary  purposes 
only.  The  author  has  many  times  made  use  of  esophagostomy  for  a 
temporary  purpose,  closing  it  after  it  has  served  its  purpose.  The 
most  striking  case  of  this  nature  was  the  case  of  extrinsic  laryngeal 
cancer  already  described  in  which  the  larynx,  the  hyoid,  a  large  por- 
tion of  the  pharynx,  the  tonsils,  the  base  of  the  tongue  and  all  of  the 
intervening  tissue  were  excised.  At  the  end  of  the  operation  no 
pharyngeal  mucosa  was  left.  The  esophagus  was  stitched  up  into  tin- 
skin  at  the  side  of  the  neck  and  was  securely  fastened  with  silk 
sutures.  The  trachea  was  stitched  to  the  opposite  side.  After  a  time 
new  mucous  membrane  spread  over  the  pharynx.  The  author  then  in 
several  stages  freed  the  esophagus  from  its  attachment  to  the  skin  at 
the  side  of  the  neck  and  brought  it  to  the  median  line.  In  two  more 
seances  he  sutured  the  large  hiatus  in  the  anterior  pharynx.  After 
a  good  union  was  secured  the  esophagostomy  opening  was  finally 
closed.  The  patient  made  an  excellent  recovery. 

In  performing  an  esophagostomy  the  important  point  is  to  make 
the  incision  so  ample  that  all  the  field  may  be  seen  clearly.  (Fig.  110.) 
The  dissection  should  bo  so  controlled  that  the  recurrent  laryngeal 
nerve,  the  big  blood  vessels,  the  vagus  and  the  other  important 
structures  may  all  be  so  clearly  soon  that  they  cannot  be  mistaken  nor 
injured.  (Fig.  111.)  If  each  step  in  the  operation — however  minute- 
is  controlled  not  the  slightest  mishap  need  occur.  After  the  esophagus 
has  been  reached,  however,  it  is  important  to  avoid  extending  the 
dissection  in  the  neck  the  least  bit  more  than  is  required;  for.  in  the 


OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 


first  place,  a  wide  dissection  is  not  needed;  and,  in  the  second  place, 
the  dee])  planes  of  tissue  in  the  neck  have  hut  little  power  of  resisting 
infection. 

If  no   emergency   exists,    it   is   even    safer   to   hring   the   esophagus 
well  u]»  into  the  wound;  to  pass  a  small  strip  of  iodofonn  gauze  around 


Esophagostomy.     Ample    incision    of  skin    alont;    the   anterior   bonier   of 
sternomastoid   muscle. 


it;  and  to  pack  the  wound  gently  for  several  days  hefore  the  esophagiu 
is  opened.  'This  point  is  not  of  sufficient  importance  however  to  justi- 
fy any  lo»  of  time.  The  fixation  of  the  esophagus  to  the  skin  is  most 
-afcly  made  hy  means  of  silk  interrupted  sutures.  (Tig.  111'.) 

The  author  has  heen  happily  surprised  to  observe  the  ease  will 
\vhicli  patients  swallow  even  \vhen  the  esophagus  is  hroughl  to  tin 
edu'e  of  the  -kin  \voi 


LAKYNX,     IMIAKYNX,     ri'l'KIt     KSOI'I  I  A<  I  TS,    AND    Tl!.\< '  1 1  KA. 


Cancer  of  the  Esophagus. — Cancel-  of  the  esophagus  is  rarely 
cured  for  usually  the  condition  is  not  recognized  until  symptoms  of 
obstruction  appeal',  by  which  time  the  disease  has  almost  certainly 
spread  into  inaccessible  territory. 

The  technic  of  resection  of  the  esophagus  for  cancel'  is  essen- 
tially the  same  as  that  already  described  for  esopliaii'ostoiny.  The 
incision  should  be  ample  enouii'li  to  expose  the  cancer  for  a  consider- 
able distance  above  and  belo\v  the  limits  of  the  cancerous  tissue.  It 
is  rarely  possible  to  unite  the  ends  of  the  divided  esophagus. 

Diverticula  of  the  Esophagus. — Operations  for  divert  iciila  of  the 


Fig.   111. 
Esophagostomy.    Exposure  of  esophagus. 

esophagus  present  a  sharp  contrast  to  those  for  pliarynuval  stricture, 
for  the  former  are  usually  successful.  The  author  has  operated  on 
five  cases  and  found  them  readily  curable. 

Before  operation  X-ray  bismuth  pictures  should  be  made  to  de- 
termine the  exact  location,  the  extent  and  the  nature  of  the  sac  which 
is  most  commonly  situated  at  the  upper  lateral  aspect  of  the  esophainis. 
often  extending  downward  below  the  clavicle  even. 

The  operation  is  performed   in   the  following  manner: 

1.     A  lon.u1  vertical  incision  is  made  over  the  middle  of  the  sac. 

'2.  By  sharp  knife  dissection  the  sac  is  exposed,  the  Held  beinu' 
kept  bloodless  and  translucent  by  picking  up  and  clamping  each 
vessel  either  before  or  at  the  moment  of  its  division. 

:>.  The  entire  pouch  or  sac  is  isolated  up  to  its  esopha.ii'eal  or 
pharyiii>'eal  point  of  origin. 


154 


OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 


4.  The  sac  is  cut  off  exactly  as  one  cuts  off  a  hernial  sac.  The 
opening  of  the  diverticulum  is  closed  by  a  silk  suture  preferably  with 
a  cobbler  stitch.  The  first  row  of  stitches  is  reenforced  by  a  second  row, 
and  a  small  drain  is  inserted  at  the  lower  end  of  the  wound  after  clos- 
ing the  overlying  tissues. 

If  the  diverticulum  be  high  up  on  the  esophagus,  especially  if  it 
involve  the  pharynx,  the  patient  should  not  be  allowed  to  swallow 
until  the  line  of  union  is  well  established.  As  the  victims  of  esophageal 
diverticula  have  usually  had  much  experience  with  throat  and 


Fig.   111'. 
Esophagostomy.    Esophagus  stitched  to  skin. 

esophageal  instrumentation,  the  insertion  of  a  small  flexible  tube 
through  which  nourishment  may  be  given  will  lie  no  hardship. 

One  of  the  author's  patients  had  had  another  diverticulum  re- 
moved twelve  years  previously.  In  this  case  the  pharyngeal  wall 
was  strikingly  thin,  and  in  addition  to  two  diverticula  the  pharynx 
was  greatly  dilated  on  the  same  side.  The  site  of  the  first  operation 
was  clearly  visible,  the  scar  being  sound.  Kot.h  diverticula  were;  re- 
moved and  in  addition  a  large  elliptical  portion  of  the  dilated  pharynx 
was  excised.  The  result  has  been  excellent. 

Diverticula  with  narrow  necks  are  of  course  the  easiest  to  remove. 


CHAPTER  V. 

LARYNGOSCOPY,  TRACHEOSCOPY,  BRONCHOSCOPY,  ESOPHAGOSCOPY, 

AND  GASTROSCOPY* 

By  Harris  P.  Mosher,  M.  1). 

THE  DIRECT  EXAMINATION  OF  THE  LARYNX. 

Historical. — Kirstein  in  1S94  introduced  the  direct  method  of  ex- 
amining" the  larynx.  The  instrument  with  which  he  accomplished  the 
exposure  of  the  larynx  was  an  elongated  tong'ue  depressor  with  hoods 
of  various  sizes.  Killian  took  up  the  procedure,  and  changed  the  flat 
speculum  of  Kirstein  into  one  of  tubular  form,  systematized  the  steps 
of  the  examination  and  won  from  the  medical  profession  the  recogni- 
tion of  its  great  value.  The  foresight  and  enthusiasm  of  Killian  have 
been  supplemented  by  the  great  inventive  ability  of  Briinings.  The 
result  of  the  labors  of  these  men  has  been  that  a  number  of  instruments 
are  available  today  for  the  direct  examination  of  the  larynx. 

The  advantages  of  the  direct  examination  of  the  larynx  arc  self- 
evident.  It  is  the  natural  method.  The  physician  works  upon  the 
larynx  in  the  same  fashion  that  a  surgeon  works  upon  any  other  part 
of  the  body.  Manipulations  in  the  larynx  carried  out  under  the  guid- 
ance of  a  mirror,  are  executed  round  a  right  angle  corner  with  the  ante- 
rior and  posterior  positions  of  the  various  parts  of  the  larynx  reversed. 
The  indirect  method  of  examining  and  operating  upon  the  larynx  must 
be  credited  with  very  great  accomplishments,  and  it  will  always  be 
employed,  but  the  special  workers  of  the  coming  generation  will  turn 
instinctively  to  direct  manipulations  upon  the  larynx  rather  than  to 
the  older  procedure. 

Contraindications. — Absolute  contraindications  to  the  employ- 
ment of  direct  inspection  of  the  larynx  are  seldom  found.  Chief  among 
these  is  a  high  grade  of  dyspnea.  The  direct  examination  should  not 
be  attempted  in  severe  cases  of  uncompensated  heart  lesions,  or  in  a 

*This  article  is  based  upon  the  writings  of  Brunings,  Kahler  and  Jackson.  The  author's  own  ex- 
perience furnishes  a  certain  small  part.  Kpitomes  of  new  work,  and  such  in  great  measure  is  this  article, 
must  go  to  the  original  sources  for  the  facts.  This  the  author  has  done.  He  wishes  here  to  make  full  and 
grateful  acknowledgment  of  his  indebtedness. 

(155) 


156  OPERATIVE    SrmiEEY    OF    THE    XOSE,    THROAT,    AND    EAR. 

case  of  advanced  aneurism.  Intractable  gagging  in  spite  of  thorough 
cocainization  is  not  so  much  a  contraindication,  although  the  result 
is  the  same,  as  it  is  an  insurmountable  obstacle.  Where  the  direct  ex- 
amination proves  to  be  impossible,  it  is  generally  due  to  uncontrollable 
reflexes.  However,  unless  there  is  some  disease  of  the  cervical  verte- 
bra1 oi1  some  unusual  malposition  ov  deformity  of  the  larynx  the  direct 
examination  is  almost  always  possible  under  general  anesthesia. 
Where  the  patient  is  suffering  from  marked  dyspnea  the  performance 
of  tracheotomy  usually  makes  the  direct  examination  possible. 

rncontrollable  gagging,  the  chief  difficulty  in  carrying  out  direct 
examination,  interferes  fully  as  much  in  the  indirect  method  as  it  does 
in  the  direct.  In  either  case  it  must  be  successfully  combatted  before 
the  examination  can  proceed. 

The  Choice  of  the  Anesthetic. —  In  examining  the  larynx  directly 
the  operator  has  the  choice  of  local  or  general  anesthesia.  Some  form 
of  anesthesia  is  necessary  on  account  of  the  gagging  and  coughing  far 
more  than  on  account  of  the  pain,  since  the  manipulations  employed  in 
the  direct  examination  of  the  larynx  and  trachea  give  rise  to  but 
little  pain.  It  is  essential,  therefore,  to  do  away  -with  the  sensitiveness 
only  of  the  mucous  membrane.  This  can  be  brought  about  either  by 
the  use  of  cocain  locally  or  by  the  production  of  general  anesthesia  in 
addition  to  local  anesthesia,  because  even  with  the  general  anesthesia, 
the  use  of  cocain  is  necessary.  "Die  operator  ought  not  be  a  partisan  in 
this  mattei'.  lie  should  employ  either  form  of  anesthesia  at  will.  Infants 
and  children  are  best  examined  under  general  anesthesia.  In  many 
adults  a  satisfactory  examination  is  possible  only  under  ether.  Certain 
systemic  diseases  like  multiple  sclerosis,  bulbar  paralysis,  tabes,  and 
hysteria,  increase  the  sensitiveness  of  the  mucous  membranes.  In  old 
subjects  the  mucous  membrane  of  the  larynx  and  trachea  is  often  very 
tolerant.  In  robust  males  with  chronic  catarrh,  twice  or  three  times  the 
amount  of  cocain  as  is  required  for  women  is  often  needed  to  produce 
anest  hesia. 

Cocainization. —  liriinings  with  his  customary  thoroughness  has 
studied  the  methods  of  cocaini/at  ion  exhaustively.  He  has  demon- 
strated that  cocain  applied  bv  a  brush  or  swab  is  three  times  as  et't'ec 

I     I  t 

live  as  it  is  when  introduced  by  a  spray.  If  adrenalin  is  added  to  the 
coca'm  solution  the  anesthesia  is  noticeably  prolonged.  l-Jriimngs  uses 
a  syringe  which  he  converts  into  a  swab  syringe  by  winding  cotton  on 
the  lip  of  the  camila.  The  barrel  of  the  syringe  is  graduated  so  that 
the  operator  can  control  the  dosage  of  cocain.  This  author  finds  that 
on  the  average  five  drops  of  a  twenty  pel'  cent  solution  is  sufficient  to 
produce  anesthesia  in  an  adult.  In  children  the  strength  of  the  solu- 


LAHYXCOSCOI'Y,     UliONCIIOSCOl'Y,     KS( )  I'  1 1  A<  ;<  )S( '( )\'\  . 

tion  is  reduced  to  ten   pet'  cent,  because  they  do  not    tolerate  the  drug 
as  well  as  adults. 

With  a  swab  or  the  swab  syringe,  a  drop  of  a  twenty  per  cent  solu- 
tion of  cocain  is  applied  to  the  base  of  the  tongue,  and  another  to  tin- 
posterior  pharyngeal  wall.  After  an  interval  of  three  or  four  minutes 
the  cocain  is  applied  to  the  tip  of  the  epiglottis.  Finally  a  drop  or  two 
is  placed  in  the  larynx.  This  calls  for  accurate  dosage.  The  writer  of 
this  article  has  not  had  any  experience  with  the  brush  or  swab  syringe, 
but  has  used  the  simple  swab  and  with  it  a  ten  per  cent  solution  of 
cocain  for  the  first  of  the  anesthesia,  and  a  twenty  per  cent  solution 
in  the  larynx.  The  weaker  solution  allows  the  cocain  to  be  employed 
more  freely.  Fntil  the  beginner  perfects  his  technic  he  will  do  well  to 
use  the  weaker  solution  for  the  most  part.  If  cocain  is  mixed  with 
adrenalin  chloride  much  stronger  solutions  can  be  used  in  the  larynx. 
Some  operators  employ  as  high  as  fifty  per  cent. 

The  Difficulties  of  the  Examination. — The  greatest  difficulty  in  the 
way  of  a  successful  examination  is  incomplete  anesthesia.  Time  is  lost 
and  the  examination  is  rendered  incomplete  or  made  impossible  unless 
the  anesthesia  is  profound.  From  its  nature  the  procedure  of  direct 
examination  is  disconcerting  if  not  alarming  to  an  inexperienced  pa- 
tient. Therefore,  the  patient  should  be  calmed  by  the  assurance, 
repeated  if  necessary,  that  he  will  not  strangle.  lie  is  encour- 
aged to  hold  the  head  as  loosely  as  he  can  and  to  breathe  quietly  and 
regularly.  From  time  to  time  the  examination  is  interrupted  in  order 
that  the  patient  may  spit  out  the  accumulated  saliva.  He  is  cautioned 
to  do  this  quietly  and  not  to  hawk.  During  the  examination  the  pa- 
tient is  liable  not  only  to  bend  the  head  too  far  back  but  to  allow 
the  whole  body  from  the  knees  up  to  swing  backward.  The  assistant 
should  see  to  it  that  the  patient  keeps  straight  and  erect.  These 
are  the  principal  and  natural  faults  into  which  the  patient  falls. 
The  faults  of  technic  to  which  the  examiner  is  liable  are  also  natural 
ones.  The  first,  incomplete  cocainization,  is  due  to  haste.  For  the 
patient's  sake  he  wishes  to  get  the  examination  over  quickly.  The  sec- 
ond mistake  on  the  part  of  the  physician  is  to  insert  the  speculum  too 
deeply  at  first  and  in  consequence  to  miss  and  to  pass  the  epiglottis  and 
to  strike  the  point  of  the  instrument  against  the  posterior  pharyn- 
geal  wall.  This  produces  uncontrollable  gauging  and  often,  for  the 
day  at  least,  makes  further  manipulation  impossible.  In  pressing  tin- 
epiglottis  and  the  base  of  the  tongue  forward  the  speculum  should  be 
held  firmly  and  the  procedure  executed  in  a  deliberate  and  unhesitat- 
ing fashion.  Otherwise  the  tongue  is  tickled  and  rebels.  Tuder  firm 
pressure  it  yields  and  submits.  When  the  tip  of  the  speculum  has  en- 


158  OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

terecl  the  larynx  there  is  danger  of  the  shaft  striking  against  the  teeth 
or  the  unprotected  gums,  thus  causing  pain.  The  examiner's  finger 
should  be  so  placed  as  to  prevent  this.  The  success  of  the  examination 
depends  most  of  all  upon  the  character  of  the  patient's  neck.  If  he  has 
a  thin  neck,  and  if  he  is  fortunate  enough  to  have  no  teeth  the  pros- 
pects of  a  successful  examination  are  good.  If,  on  the  contrary,  the 
patient  has  a  short,  thick  neck,  and  a  protruding  upper  jaw  and 
retains  all  his  teeth,  the  outlook  for  the  examination  is  not  so  hopeful. 
The  amount  of  force  required  to  bring  the  larynx  into  view  varies 
with  the  individual  neck.  Briinings  has  made  the  observation  that  a 
force  of  10  kg.  is  bearable,  15  kg.  painful,  and  20  kg.  unbear- 
able. He  has  found  also  that  the  ease  of  seeing  the  anterior  commis- 
sure varies  greatly;  in  fact  it  may  be  thirty  times  as  difficult  in  one 
patient  as  in  another.  The  harder  it  is  to  obtain  a  view  of  the  anterior1 
commissure  the  smaller  must  be  the  diameter  of  the  speculum.  With 
a  speculum  of  9  mm.  diameter  a  pressure  of  9  kg.  will  expose  the 
anterior  commissure.  With  a  speculum  of  14  mm.  diameter  the  same 
amount  of  force  will  expose  only  the  posterior  part  of  the  larynx. 

The  Method  of  Making  the  Direct  Examination. 

The  patient  should  be  examined  if  possible  when  the  stomach  is 
empty.  If  the  physician  feels  that  his  patient  will  be  unruly  a  dose 
of  bromid  or  morphin  some  little  time  before  is  of  benefit.  The  patient 
is  seated  upon  a  low  stool  (30  cm.  in  height),  and  the  assistant  stands 
behind  and  supports  the  head.  The  patient's  head  is  bent  slightly 
backward. 

The  patient  protrudes  his  tongue  and  holds  it  with  his  left  hand. 
The  examiner  guards  the  upper  teeth  of  the  patient  with  the  forefinger 
of  his  left  hand  at  the  same  time  pushing  the  upper  lip  out  of  the 
way.  The  thumb  of  the  left  hand  is  held  against  the  left  forefinger  and 
the  angle  between  the  two  fingers  is  made  to  serve  as  a  guide  for  the 
shaft  of  the  speculum.  Two  forms  of  specula  are  used  for  direct  exam- 
ination, the  tubular  speculum  of  Jackson  (Figs.  11.'!  and  114)  and  the 
speculum  of  Briinings.  Suppose  that  the  instrument  of  Jackson  is  the 
one  which  the  examiner  is  using.  It  is  manipulated  ;is  follows:  The  blade 
of  the  speculum  is  carried  into  the  mouth  along  the  central  line  of  the 
tongue  until  the  tip  of  the  epiglottis  appears.  As  soon  as  this  is  rec- 
ognized the  end  of  the  speculum  is  carried  over  it.  This  is  the  first 
stage  of  the  examination,  if  for  purposes  of  clearness  the  examination 
is  described  in  stages.  It  is  vital  for  the  success  of  the  examination 
not  to  have  this  first  manipulation  miscarry.  When  the  epiglottis  has 
been  passed  by  the  tip  of  the  speculum,  the  handle  of  the  instrument 


LARYXGOSCOL'Y,    JJKOXCHOSCOl'Y,     KSOI'H  A<  i(  >S( '( M'Y  ,     K  I  (  .  15!) 

is  gently  raised  and  at  the  same  lime  the  patient's  head  is  allowed  to 
swing  backward  slightly  and  by  degrees.  As  the  head  of  the  patient 
goes  back  the  end  of  the  speculum  is  pushed  downward  along  the 
posterior  surface  of  the  epiglottis  into  the  vestibule  of  the  larynx. 
From  the  moment  that  the  tip  of  the  epiglottis  has  been  passed  until 
a  satisfactory  view  of  the  larynx  is  obtained,  firm  pressure  is  kept  upon 
the  base  of  the  tongue  by  lifting  up  the  handle  of  the  speculum  and 
thus  forcing  its  shaft  and  tip  forward.  The  discovery  and  the  passing 
of  the  tip  of  the  epiglottis  constitute  the  first  stage  of  the  examination, 
the  sinking  of  the  speculum  into  the  vestibule  of  the  larynx  the  second, 
and  the  pushing  of  the  epiglottis  and  the  base  of  the  tongue  forward, 


Fig.    113. 

Jackson's  tubular  speculum.  The  instrument  is  made  in  two  sizes,  for 
children  and  aduHs.  Johnson  has  modified  this  speculum  by  making  the 
horizontal  part  of  the  handle  detachable. 

the  third  stage1.  If  at  any  time  the  examiner  loses  his  way,  that  is, 
misses  the  epiglottis,  or  strikes  the  posterior  pharyngeal  wall  or  finds 
himself  in  the  pyriform  sinus,  the  speculum  should  be  withdrawn  and 
the  examination  started  again  from  the  beginning.  It  is  a  help,  after  the 
tip  of  the  epiglottis  has  been  passed  and  the  speculum  is  about  to  enter 
the  vestibule  of  the  larynx,  to  ask  the  patient  to  speak,  in  order  that 
the  movement  of  the  arytenoid  cartilages  may  give  the  proper  direction 
for  the  deeper  introduction.  A  successful  examination  should  be  a 
matter  of  only  a  few  minutes. 

Passing  the  Speculum  from  the  Corner  of  the  Mouth. — If  there 
happens  to  be  a  sufficient  u'ap  between  the  teeth  on  either  side  of  the 
upper  jaw  advantage  may  be  taken  of  this  space  to  pass  the  speculum 


160 


OPERATIVE    STRtiERY    OF    THE    NOSE,    THROAT,    AND    EAR. 


at  this  place.  If  no  <i'ap  exists  and  the  incisor  tooth  arc  prominent,  the 
speculum  may  be  passed  between  the  bicuspid  teeth  or  from  the  corner 
of  the  mouth.  The  distances  are  shorter  and  the  muscles  more  relaxed. 
For  this  purpose  the  head  of  the  patient  is  rotated  a  little  and  bent 
slightly  to  the  opposite  side.  Tarried  out  with  a  small  .Jackson  spec- 
ulum this  method  of  making  the  direct  examination  is  very  successful 
in  children  and  infants.  This  procedure  has  been  especially  developed 
by  Johnston. 

The  Direct  Examination  With  Counter  Pressure. — In  the  direct 
examination  it  is  the  forward  pressure  of  the  speculum  which  enables 
the  operator  to  see  the  larynx,  but  this  at  the  same  time  limits  his  view 
because  the  larvnx  as  a  whole  is  dislocated  considerablv  forward.  In 


Fig.   114. 


Diagrammatic  representation  of  direct  laryngoscopy  and  schema,  show- 
ing direction  of  force  applied  in  using  the  tubular  speculum.  (After  Jack- 
son. ) 


order  to  counteract  this  the  operator  almost  instinct  ively  puts  his 
finder  on  the  larynx  from  the  outside  and  pushes  it  backward.  Briin- 
in,u's  has  .u'iven  this  common  manipulation  a  special  name,  direct  exam- 
ination with  counter-pressure,  and  has  devised  an  instrument  to  do 
the  work  of  the  physician's  hand,  and  so  free  it  for  other  uses.  With 
this  instrument  the  inventor  states  that  the  anterior  commissure  can 
be  seen  in  all  cases. 

The  Direct  Examination  Under  Ether.  The  patient  is  prepared 
for  li'cneral  anesthesia  in  the  usual  way.  Before  he  comes  to  the  exam- 
ining table  he  is  u'iven,  if  an  adult,  a  sixth  of  a  irraiu  of  morphin  and 
one  one-hundred  and  fiftieth  of  a  .u'rain  of  atropin.  The  patient  is 
placed  on  his  back'  on  a  table  hiii'h  enoii.u'h  to  briu.u'  the  head  to  the 
same  level  as  the  face  of  the  examiner  if  he  prefers  to  work  sitting.  If 
he  prefers  to  work  standing  the  table  is  put  upon  a  platform.  The 


LAKYXOOSCOl'Y,     HKONCIIOSCOI'Y, 


author  has  found  it  less  tiring  and  less  awkward  to  make  tin-  examina- 
tion standing.  (Figs.  115  and  ll(i.)  The  head  and  shoulders  of  UK-  pa- 
tient are  brought  over  the  end  of  the  table  while  an  assistant  supports 
the  head  with  his  left  hand  upon  his  left  knee.  The  knee  of  the  assist- 
ant is  supported  at  the  proper  height  by  an  adjustable  foot  rest.  When 
the  ether  has  been  well  started  the  physician  cocainizes  the  deep  phar- 
ynx of  the  patient  and  the  region  of  the  pyriform  sinuses  with  a  swat) 


Fig.  115. 

Position  of  second  assistant  and  patient  for  endoscopy  per  os.     (Jo\vns. 
caps  and  covers  are  omitted  to  show  the  position  better.      (After  Jackson,  i 

saturated  with  a  ten  per  cent  cocain  solution.  Often  it  is  a  help  to 
have  a  suture  through  the  tongue.  The  introduction  of  the  spec- 
ulum is  the  same  as  under  local  anesthesia  except,  of  course,  that  in 
the  majority  of  cases  it  is  easier.  The  ether  examination  is  resorted 
to  when  the  patient  is  intractable  under  local  anesthesia.  It  is  used 
in  the  case  of  children,  or  when,  besides  making  an  examination,  oper- 
ations of  considerable  extent  are  to  be  carried  out.  The  assistant 
should  so  hold  the  head  of  the  patient  that  he  can  at  any  moment 


1()2  OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 

transfer  it  to  the  hand  of  the  physician.  Often  the  physician  can  obtain 
a  better  view  by  manipulating  the  position  of  the  head  for  himself. 
In  a  hard  examination  the  head  passes  many  times  from  the  hand  of 
the  assistant  to  the  hand  of  the  examiner.  The  assistant's  free  hand 
is  ready  at  any  moment  to  push  the  larynx  back  and  to  manipulate  the 


Fix.   116. 

Bronchoscopy  room  at  Massachusetts  General  Hospital.  The  elevated 
platform  is  shown,  with  the  operating  table  and  the  assistant  who  holds  the 
patient's  head.  The  rheostat  and  dry  cell  battery  are  seen  on  the  wall  at  the 
left.  Behind  the  assistant  is  a  Coakley  lamp.  On  the  left  also,  but  not 
shown  in  the  photograph,  are  the  electric  suction  pump  and  the  ground 
glass  box  for  holding  X-ray  plates. 


anterior  commissure  into  view,  or  to  close  the  cords  in   order  to  show 
the  presence  of  a   new  .u'rowth. 

In  examining  children  under  ether  it  is  not  always  necessary  to 
brinir  the  head  over  the  end  of  the  table.  If  the  occiput  is  allowed  to 
rest  on  the  table  and  the  chin  is  brought  up,  in  very  many  instances  a 
perfect  view  can  be  obtained.  It  is  well  to  1  ry  this  posit  ion  first.  (  M'ten 


LARYNdOSCOPV,     BKOXCHOSC'Ol'Y,     KSOIM  I  A<  lost 'opy  .     KT< ' 


this  position  is  successful  also  with  adults.  If  i' 
does  not  succeed  the  head  may  be  turned  to  tin- 
side  and  the  speculum  carried  down  between 
the  bicuspid  teeth  or  from  the  corner  of  tin- 
mouth.  This  manipulation  is  especially  useful 
for  introducing  the  bronchoscope  between  tin- 
cords  because  it  is  easier  to  get  in  line  with  the 
trachea  in  this  way  than  it  is  from  the  middl" 
line. 

For  operating  purposes  Briinings  employs  an 
open  speculum.  Some  years  ago  the  author  de- 
vised practically  the  same  kind  of  a  speculum, 
and  used  it  for  some  time  but  soon  replaced  it 
by  an  open  adjustable  speculum  of  the  pattern 
shown  in  Figs.  117  and  118.  An  open  speculum 
increases  the  operating  field.  Such  a  spec 


Fia.   117. 


Mosher's   adjustable   speculum    for   direct    and    suspension    laryngoscopy 
(  Side  view.) 


164 


OPERATIVE    STRCERV    OF    THE    XOSE.    THROAT,    AND    KAK. 


IT 


Mosher's  adjustable  specu- 
lum, showing  the  mechanism 
by  which  the  speculum  can  be 
adjtisted  to  any  width. 


is  tlie  only  pattern  through  which  direct  in- 
tubation with  the  larger  tubes  can  be  per- 
formed. The  eye  strain  in  using  the  open 
speculum  is  lessened.  All  the  landmarks  of 
the  pharynx  and  larynx  are  visible  at  once 
and  in  their  natural  perspective.  The  writer 
is  very  partial  to  the  open  speculum  when  it 
can  be  employed.  In  children  it  is  especially 
successful.  In  appropriate  necks  of  adults 
it  is  also  successful.  The  author  always  tries 
this  form  of  speculum  first  because  when  it 
succeeds  no  other  speculum  gives  as  good  a 
view.  The  open  speculum  may  be  used  with 
or  without  general  anesthesia.  However, 
with  infants  and  young  children  for  obtain- 
ing a  diagnostic  view  of  the  larynx,  for  in- 
tubation, for  extubation,  or  for  removing 
coins  from  the  upper  part  of  the  esophagus 
it  can  be  employed  without  ether. 

The  Instruments  for  Direct  Examina- 
tion and  Direct  Operating. — The  examining 
instruments  are  the  tubular  speculum  of 
Jackson,  the  speculum  of  Briinings  lighted  by 
the  electroscope,  and  fitted  with  the  attach- 
ment for  counter-pressure,  and  some  form  of 
open  speculum.  The  light  for  the  open  spec- 
ulum may  be  obtained  by  Jackson's  melhod, 
or  by  reflection  from  a  head  mirror.  The  in- 
struments used  through  Hie  various  specula 
in  direct  operating  upon  the  larynx  are  made 
with  the  shaft  of  the  proper  length  and  at  an 
appropriate  angle  with  the  handle.  Tli<i  first 
instrument  is  the  laryngeal  knife.  The  other 
instruments  come  under  the  head  of  punches 
or  grasping  forceps.  (Fig.  119.)  The  shaft 
of  the  instruments  should  be  as  thin  as  pos- 
sible and  retain  its  rigidity.  The  instruments 
of  Briinings  are  most  excellent.  In  using  in- 
struments which  work  with  a  scissor  motion 
it  is  hard  to  judge  when  they  are  placed  at 
the  proper  depth.  They  either  fall  short  or 
overreach  the  growth  to  be  seized.  It  is 


LAKYNtiOSOOI'Y,     Illio  N< '  1 1  osrol'Y  ,     l-'.Si  il'l  I  .M  ;os< '( »l'\",     I. '!'«'.  I').) 

easier  to  adjust  accurately  an  instrument  1  lie  blades  of  \\  hidi  are  placed 
at,  riu'ht  angles  to  the  end  of  Hie  shaft  and  which  close  upon  each  oilier 
from  above  downward.  The  lower  blade  ean  be  carried  below  the 
UTowth  and  then  brought  upward  until  the  movement  of  the  in'owlh 
shows  that  the  blade  is  touching  it  from  below.  If  the  blade-  are  then 
shut  the  bite  is  usually  successful. 

In  hard  examinations  where  neither  the  position  of  the  head  nor 
counter-pressure  will  cause  the  speculum  to  brinu'  about  a  sufficient 
view  of  the  larynx,  and  the  writer  must  confess  that  he  has  had  such 
cases — a  small,  short  bronchoscopo  introduced  from  the  an.u'le  of  the 
mouth  will  at  times  brin.u1  into  view  the  desired  part  of  the  larynx. 
The  writer  well  remembers  a  youn.u1  sailor  of  splendid  physique  who 
had  a  small  fibroma  situated  well  forward  on  the  left  vocal  cord.  I  nder 
ether  a  most  trying  and  humiliatiu.u1  examination  followed.  Success 
however  followed  when  a  small  brouchoscope  was  introduced  from  the 
anu'ie  of  the  mouth  on  the  ri.u'ht  and  carried  into  and  across  the  larynx 
until  the  growth  was  pinned  inside  the  tube  and  against  the  lateral 
wall  of  the  larynx.  An  assistant  meanwhile  pressed  the  larynx  back- 
ward and  made  counter-pressure  on  the  left. 

A  working  set  of  instruments  for  bronchoseopv  is  as  follows: 

1.  Jackson's  tubuh-r  speculum    (j'dult   ;;;:<!  child   size). 

-.  Jackson's  bronchoscom  x    (7,   8.5.   ]n.   ;:ml    li'   mm.   in    diameter). 

:!.  13r;inings'   universal   electroscope. 

4.  Hriinings'  extension  double  tubes   (7.  8.5.  in.  u>.  and   11  mm.   in   diameter). 

5.  Briinings'   autoscope   or  split   spatula   speculum    (11    and    i:'>   mm.    in   diameti-n. 
I!.  nriinings'   extension    forceps   with   five   different    tips:    or   Jackson    forceps    with 

tips;    or   Coolidgo   forceps   with   shaft   of  three   lengths   and   Tips. 
7.     Suction    apparatus    (hand    buib.    hand    or    electric    aspirator,    witli    tline    tube.; 

25,  35.  and  50  cm.  in  hngth). 
S.     Foreign  body  hook. 
!i.     Casst-lbcrry's  pin   cutter;    or   Moshor's  pin   brndi  r. 

10.  Brunings'    or    Mosher's    safety    pin    closer. 

11.  Jackson's   dilator    for   the   bronchi. 
1L'.     Mosher's   adjustable   speculum. 

i:1,.  Two   angular   locking   forceps,    for   us-    with    the   npni    sjieculum    (Mosherl. 

14.  Twelve   Coolidge's   cot  ion   carriers. 

15.  Kirstein's   head   light. 
K).  Angular  laryngeal   knife. 

17.      Ring  punch,   for   work   about    the   mouth   of  the   i  sopluuvus    (Moshtr). 


fourth.  The  latter  is  an  eas; 
larynx  and  the  mouth  of  the  esophagus.  It  is  economy  to  have  all  four 
in  the  operating  room.  The  writer  has  his  examining  table  in  a  special 
which  is  u'iven  up  to  bronchoscopy  and  esophau'oscopy.  The  table 


OPERATIVE    Sl'RtiERY    OF    THE    NOSK,    THROAT,    AND    EAR. 


(Fig.  116)  stands  on  a  platform  the  left  corner  of  which  is  cut  out  to 
allow  standing  room  for  the  operator.  On  this  platform  beside  the 
examining  table  there  is  room  for  the  etherizer  and  the  assistant  who 
holds  the  head  of  the  patient.  On  the  right  on  a  wall  bracket 
is  a  Coakley  rheostat.  Below  this  is  another  shelf  for  the  Jackson 
double  dry  cell  battery,  and  on  the  platform  is  an  electric  light  on  an 
upright  stand.  On  the  right  also  is  placed  an  electric  aspirating  pump. 
Each  piece  of  apparatus  is  connected  with  its  own  socket.  .V  Kirstein 
head  light  is  kept  at  hand.  In  the  complete  operating  room  there 
should  be  an  illuminated  box  with  a  ground  glass  face  for  holding  and 
demonstrating  X-ray  plates. 

The  table  for  instruments  is  placed  behind  and  to  the  right  of  the 
operator.  Beside  the  table  and  behind  and  on  the  right  stands  the 
first  assistant.  Opposite  the  first  assistant  but  on  the  other  side  of  the 


Fore-ops     for   direct     work     upon     the     larynx.       (Pt'an.)       Various     tips 
(natural    size)    arc   shown    bolow    the    forceps. 

fable  is  the  nurse.  It  is  the  duly  of  the  nurse  to  load  the  cotton  car- 
riers. She  should  see  to  it  that  a  good  number  of  these  are  always 
ready  so  that  the  operator  may  never  have  to  wait.  The  swabs  are 
loaded  either  with  cotton  or  better  with  small  pieces  of  selvedged 
gau/e  cut  and  folded  to  the  proper  size.  It  is  of  the  utmost  importance 
that  the  nurse  and  the  first  assistant  should  know  how  to  fasten  the 
swabs  securely  to  the  carriers.  When  the  operator  is  looking  down  a 
tube  he  should  not  be  required  to  turn  his  head  in  order  to  receive  an 
instrument.  When  he  asks  for  one  the  first  assistant  not  only 
pas>cs  it  to  him  over  his  shoulder  but  places  the  end  of  the  instru- 
ment in  1  he  m  out  h  of  t  he  tube  and  its  handle  in  t  he  hand  of  t  he  operator. 
I'eforc  beirinnin.u'  the  examination  all  instruments  should  be  tested 
ami  proved  to  be  in  working  order.  Ivxtra  lights  should  be  on  hand; 
or  what  is  belter,  if  the  Jackson  bronclmscopc  is  used,  an  extra  light 


LAKYMiOSCOI'N  ,     Illio  X  < '  1 1  Osroi'Y  .     KSOI'  1 1  A<  ;<  )S(  'o|'\  .     KTC.  l(i~ 

carrier  with  a  tested  light  should  he  in  readiness.  The  assistant- 
should  know  how  to  change  the  lights  and  how  to  adjust  the  instru- 
ments. 

Every  detail  should  he  provided  for  het'ore  the  examination  is  be- 
gun. The  operator  must  he  willing  to  supervise  the  smallest  details- 
it'  he  wishes  the  examination  to  go  <|iiiekly  and  smoothly.  The  suc- 
cess  of  the  operation  often  depends  upon  the  thoroughness  of  the  prep- 
aration. 

On  an  accessory  tahle  the  instruments  for  tracheotomy  should  he 
sterilized  and  ready  for  use.  There  should  he  enough  assistant-  for 
carrying  out  this  procedure  and  they  should  he  surgically  trained. 

The  Inhalation  of  Oxygen. — A  cylinder  of  oxygen  gas  should  he 
in  every  operating  room  for  use  in  cases  calling  for  bronchoscopy.  The 
administration  of  the  gas  may  make  it  possihle  to  avoid  a  trache- 
otomy if  severe  dyspnea  is  present,  while  the  use  of  the  gas  to  combat 
shock  and  respiratory  arrest  is  important.  If  a  bronehosoopc  is  in 
place  when  the  emergency  arises  the  gas  may  he  administered  through 
this  directly,  or  through  the  suction  tube  if  the  .Jackson  type  of  bron- 
choscope  is  employed.  Daeger  has  devised  an  apparatus  by  which  the 
amount  of  oxygen  administered  can  be  accurately  measured  and  eon- 
trolled. 

Suspension  Laryngoscopy. 

About  three  years  ago  Killian  introduced  suspension  laryngos- 
copy.  Within  the  last  twelve  months  his  perfected  instruments  have 
begun  to  be  used  extensively.  The  underlying  principle  of  the  pro- 
cedure is  the  transference  of  the  weight  of  the  patient's  head  from  the 
hand  of  the  examiner  to  the  handle  of  the  speculum.  This  u'ives  the 
physician  a  new  hand,  his  left,  with  which  to  work.  The  suspension  is 
accomplished  by  elongating  the  handle  of  the  speculum,  and  eiidinir 
it  in  a  hook.  To  this  handle  is  attached  a  skeleton  mouth-gag.  A  nut 
and  a  screw  in  the  handle  of  the  speculum  control  the  width  of  this. 
A  second  nut  and  screw  elevate  the  tip  of  the  speculum.  Spatula1  of 
different  sizes  are  fitted  upon  the  handle.  Kach  of  these  has  incorpor- 
ated in  it  a  narrow  secondary  spatula.  The  position  of  the  tip  of  this 
is  again  regulated  by  a  nut  and  screw.  The  apparatus  is  efficient  and 
beautiful,  but  complicated.  The  claim  is  made  for  it  that  besides  hold- 
ing the  patient's  head  it  will  always  bring  the  anterior  commissure 
of  the  larynx  into  view.  The  writer's  experience  with  the  apparatus 
as  yet  is  too  limited  to  pass  on  such  a  statement,  but  from  what  he 
saw  at  Killian's  demonstration  in  London  in  li'i:>.  and  from  what  he 
has  learned  from  the  men  in  this  country  who  have  employed  the 
method  and  Killian's  instruments  exteusivelv.  he  considers  this  state- 


168 


OPERAT1VK    STRtiKRY    OF    THE    XOSK,    THROAT,    AND    EAR. 


ment  much  too  broad.  This  is  relatively  a  small  matter,  of  course,  be- 
cause there  will  always  be  a  percentage  of  cases  in  which  neither  a 
speculum  nor  the  human  hand  can  force  the  anterior  commissure  hack 
into  the  field  of  vision.  The  gist  of  the  matter  is  that  an  advance  has 
been  made,  how  great  time  alone  can  settle,  by  the  introduction  of 
suspension.  The  tired  laryngologist  eagerly  grasps  the  relief  which  it 
affords.  (Fig.  120.) 

The  way  having  been  shown  by  Killian,  the   rest   of  the  world   of 


Fit;.   120. 
Killian's  susp<  nsioii  apparatus. 

laryngologists  will  rush  in  with  possible  improvements  of  the  ap- 
paratus, aiming  especially  to  simplify  it.  The  writer  admits  that  lie  is 
one  of  those  who  have  made  such  an  attempt.  A  hook  in  the  end  of  the 
handle  of  his  adjustable  speculum,  one  nut  and  angle  lever  in  the 
shank,  and  a  set  of  cross  ridges  on  the  moving  blade  convert  it  as  ex- 
perience has  shown,  into  a  serviceable  suspension  speculum.  It  can 
be  hung  from  a  chain  attached  to  the  ceiling  or  as  Murphy  suggested, 


LAUYNCOSCOI'Y,     BUOXCHOSCOPY,     KSOPJI  A<  JOSCOl'Y. 

from  the  frame  of  an  adjustable  instrument  tray  holder.  'The  reader 
\vill  doubtless  think  of  other  ways.  The  crane  of  Killian  is  efficient, 
of  course,  but  it  is  bulky  and  does  not  fit  every  table.  For  convenience 
in  carrying  the  writer  has  had  a  folding  frame  constructed.  The  board 
which  supports  this  slips  under  the  back  of  the  patient.  So  far  it  has 
met  expectations.  ("Fi&'s.  121  and  122.) 


Fig.  ll'l. 
Mosher's    folding    frame    for    suspension    apparatus    closed. 


Fig.  1-2-2. 
Mosher's    folding    frame    for    suspension    apparatus    open. 


170 


Oi'KKATIYK    STRtiKHV    OK    T 1 1  K     XOSK.    THROAT,    AND    HA!!. 


TRACHEOBRONCHOSCOPY. 

The  direct  examination  of  the  trachea  and  the  bronchi  can  be  car- 
ried out  by  two  routes.  By  the  upper  route  the  tube  is  inserted  be- 
tween the  vocal  cords.  When  the  lower  route  is  employed  the  tube 
ii'ains  access  to  the  trachea  through  a  tracheotomy  wound.  After  the 
performance  of  the  tracheotomy  the  second  method  is  the  simpler  and 
so  will  be  described  first. 

Lower  Tracheobronchoscopy. 

I'nless  the  lower  route  is  used  for  the  extraction  of  a  foreign  body 
it  is  well  to  wait  a  few  davs  until  the  surgical  wound  has  healed  a  little 


I'rct hrascopr    used    as    a 


before  attempting  thorough  examination  of  the  trachea  and  the  bron- 
chial tree.  The  earliest  examinations  of  the  trachea  by  the  lower  rout>- 
were  made  through  short  tubular  specula  like  the  female  urethraseopo, 
and  the  illumination  was  obtained  from  a  head  mirror  ( ( 'oolidi^'e. )  At 
the  present  time  self-lighted  specula  of  this  pattern  are  made.  (  File's. 
ll'.'J  and  \-4.)  For  the  examination  of  the  trachea  as  far  as  the  bifurca- 
tion these  are  the  simlest  and  best  instruments. 


LARYNOOSCOI'Y,     UliO.M  '  I  lOSCOl'Y  ,     I-;S(  (l'IIA<;oS<  '< 


Contraindications  to  Lower  Tracheobronchoscopy.  I'nless  tra- 
cheotomy is  contraindicated  the  performance  of  lower  tracheobron- 
choscopy  is  permissible  except  in  the  presence  of  pneumonia. 

Anesthesia.-  —  After  a  recent  tracheotomy  in  a  case  in  which  the 
mucous  membrane  is  normal,  a  drop  of  ten  per  cent  cocain  with  adren- 
alin added,  placed  in  the  trachea  is  sufficient  to  produce  anesthesia. 
Only  in  the  region  below  t  lie  glottis  is  there  excessive  sensitiveness.  The 
trachea  tolerates  the  tube  well.  After  the  insertion  of  the  tube  the 


Fi.ff.   ll'4. 

Urothrasoope    used    as    a    traohoosoopi 
showing     individual     parts. 


swab  syringe  may  be  used  to  apply  cocain  to  the  walls  of  the  trachea, 
the  most  sensitive  part  being  the  anterior  wall.  In  patients  who  have 
been  wearing  a  traclieal  caiiula  for  some  time  the  mucous  membrane 
about  the  tube  is  very  irritable  and  it  may  be  impossible  to  cocainize 
it.  In  children  the  strength  of  the  cocain  solution  should  be  reduced 
to  five  per  cent  and  in  adults  in  the  presence  of  bronchitis  a  twenty  per 
cent  solution  should  not  be  used  or  should  be  employed  sparingly.  If 
there  is  a  foreign  body  in  the  trachea,  the  cocainization  should  be  ac- 
complished with  a  syringe,  not  witli  a  swab.  The  parts  of  the  trachea 


172  oi'KiiATivF.  srnoF.nv   OF  TIII-:   XOSK.  THROAT.  AND  KAK. 

which  are  the  most  irritable  are  the  neighborhood  of  the  fistula,  the 
bifurcation,  and  the  bronchi  below.  The  inflamed  mucous  membrane 
about  a  foreign  body  is  always  sensitive. 

Position  of  the  Patient. — Lower  traclieobronchoscopy  is  easiest 
when  performed  with  the  patient  sitting.  After  a  fresh  tracheotomy 
or  if  the  patient  is  weak,  the  prone  position  is  better.  When  a  search 
is  to  be  made  for  a  foreign  body  the  patient  should  be  examined  on  his 
back  and  with  the  head  lowered.  If  the  prone  position  causes  cough- 
ing or  interferes  with  the  breathing  the  erect  position  of  the  patient 
is  the  only  choice.  Better  control  is  obtained  with  children  if  they  are 
placed  on  the  back. 

In  some  cases  the  examination  succeeds  best  if  the  head  of  the 
patient  is  extended  over  a  roll  or  if  a  sandbag  is  placed  under  the  neck, 
as  is  customary  in  the  performance  of  tracheotomy.  In  other  cases 
the  head  is  held  over  the  end  of  the  table. 

The  Method  cf  the  Examination. — The  ideal  method  of  learning 
bronchoscopy  is  to  make  use  of  a  patient  who  has  had  a  tracheotomy 
performed. 

The  introduction  of  the  examining  tube  offers  some  difficulty  un- 
less it  is  done  at  the  time  of  the  tracheotomy  when  the  tissues  of  the 
neck  are  wide  open,  and  the  trachcal  incision  can  be  spread  with  re- 
tractors. (Figs,  IL'.'J  and  124.)  After  the  complete  healing  of  the  wound 
about  the  tracheotomy  tube  the  fistula  into  the  trachea  is  more  or  less 
oblii|ue.  and  is  always  narrowed  from  its  original  dimensions.  The 
easiest  way  to  insert,  the  tube  without  abraiding  the  edges  of  the  fis- 
tula is  to  place  a  snugly-fitting  elastic  bougie  through  and  beyond  the 
tube,  and  then  after  having  inserted  the  projecting  erd  of  the  bougie 
throii.u'h  the  fistula  and  well  into  the  trachea  to  push,  the  tube  down  on 
the  bougie.  The  bougie  guides  the  tube  into  the  trachea  and  keeps  it 

erlor  wall  and  centers  it  in  the  long  axis  of  the 
Naturally  the  posterior  wall  of  the  trachea  is 
the  easiest  to  examine.  The  side  walls  offer  some  difficulty  but  the 
anterior  wail,  especially  in  the  neighborhood  of  the  fistula,  is  the 
hardest  of  all  to  inspect.  In  order  to  accomplish  this  the  patient  's  he,",d 
mu.-t  be  turned  strongly  to  one  side  so  that  the  tube  can  be  made  to  lie 
flat  wit  h  1  he  neck. 

If.  in-te;i<l  of  inserting  the  tube  downward  it  is  inserted  into  the 
trachea  with  the  point  upward,  the  be^inniim'  of  the  trachea  and  the 
-Tibii'lottic  region  of  the  larynx  may  be  examined.  Such  an  examina- 
tion may  be  called  for  in  cases  of  adhesions  between  the  cords  after 
diphtheria  or  when  there  is  subglottic  narrowing  due  to  the  contrac- 
tion  of  -ear  tissue.  Tins  method  is  called  retrograde  examination.  For 


LAKYNKOSCOl'Y,     I'.KO.Xf  '  1  1  OSCOI'Y  ,     KSOI'H  A<  ;OS(  'Ol'Y,     KTC.  \i.> 

this  procedure  smaller  lubes  are  necessary  in  order  thai  Hie  breathing 
may  not  he  interfered  with. 

To  return  to  the  direct  exaininat  ion  of  the  lower  part  of  Ihe  1  ra- 
chea.  If  it  is  possible,  to  employ  a  large  tube,  just  as  soon  as  this  is 
well  engaged  in  the  lumen  of  the  trachea  the  observer  usually  can  see 
the  whole  of  the  trachea  to  the  bifurcation.  It  may  be  necessary  oc- 
casionally to  draw  the  tube  to  one  side  in  order  to  accomplish  this.  'Flic 
color  of  the  trachea  varies  in  different  patients  from  a  yellowish  to  a 
blood-like  red.  If  the  walls  of  the  trachea  are  painted  with  adrenali 
solution  less  light  is  absorbed  and  the  illumination  is  increased.  Th 
tube  slips  down  the  trachea  almost  of  itself  and  the  beginner,  often,  un 


n 


\s> 


Fig.   lL>ti. 
Jackson's  bronchoscope,  with  beveled  end. 

less  lie  keeps  his  bearings  by  moving  the  tube  from  side  to  side,  misses 
the  bifurcation  and  carries  the  tube  into  the  right  main  bronchus.  In 
this  connection  it  should  be  borne  in  mind  that  the  median  septum  is 
often  pushed  far  to  the  left.  The  septum  should  always  be  located  be- 
fore the  tube  is  passed  into  a  bronchus. 

The  Endoscopic  Picture. — In  a  tubular  organ  like  the  trachea 
having  a  constant  lumen,  when  the  observer  looks  through  the  bron- 
choscope he  sees  at  some  distance  ahead  of  the  end  of  the  tube  the 
lumen  of  the  trachea  and  its  walls.  (Figs.  125  and  12(1)  The  beginner 
is  liable  to  introduce  the  tube  too  far  at  first  and  not  to  get  the  picture 
in  perspective.  If  this  is  done  pathologic  narrowing  of  the  lumen  would 
not  be  recognized.  The  same  would  be  true  of  any  deformity  of  the 
walls  caused  by  pressure  of  the  neighboring  organs.  In  order  to  ob- 


174 


OPKRATIVK    STKOKIty     OF    THE    NOSH.    THROAT.    AND    KAII. 


tain  a  proper  perspective  the  tube  should  be  held  high,  but  for  a  good 
view  of  the  walls  the  tube  should  be  carried  well  down  and  as  near  to 
the  wall  to  be  examined  as  possible.  The  higher  the  tube  the  larger  the 
field  which  appears  iu  perspective  beyond  it,  the  deeper  the  tube  the 
smaller  and  clearer  the  field,  lu  order  to  obtain  a  clear  picture  of  the 
walls  the  tube  should  not  only  be  introduced  well  into  the  trachea, 
but  the  end  should  be  displaced  strongly  to  the  side.  The  trachea 


Cast  of  the  interior  of  the  trachea  and  bronchi,  with  their  chief  ramifica- 
tions within  the  lung.  This  cast  shows  a  type  of  division  frequently  met 
with,  the  right  bronchus  being  almost  in  continuation  of  the  line  of  the 
trachea.  <i.  epartcrial  brunch:  //.  <.  hyparterial  branches  (ventral  and 
dorsal  ) .  (  Quain,  after  Aeby. ) 

and  the  bronchi  are  so  movable  that  this  procedure  is  constantly  prac- 
ticed. Indeed,  the  movability  of  the  bronchia!  tree  is  as  important  for 
the  success  of  bronchoscopy  as  is  the  forward  dislocation  of  the  base 
of  the  tongue  for  the  performance  of  direct  inspection  of  the  larynx. 
In  bronchoscopy  the  observer  should  look'  ahead  of  the  tube.  The  eye 
should  precede  and  guide  the  tube  and  the  hand. 

The  elasticity   of  the   bronchial    tree   makes   the     lateral     displace- 
ment   bv    the    examining    tube    painless.     The    lateral    mobility    of    the 


LARYNGOSCOPY,    JiHONCHOSCOPY,    KSOIM  l.\<;os<  'ol'N  ,     I-.TC.  ]  t ,) 

bronchial  tree  is  utilized  to  the  greatest  extent  in  bringing  tin-  first 
branch  of  the  left  main  bronchus  into  view.  In  addition  the  tube  is 
placed  in  the  corner  of  the  mouth  and  the  head  of  the  patient  is  bent 
sidewise  toward  the  operator.  The  median  septum  of  the  trachea  and 
the  great  vessels  suffer  in  this  manipulation  a  displacement  of  .">  cm., 
and  the  bronchi  and  neighboring  structures  a  dislocation  of  10  cm. 


Cast  of  the  interior  of  the  trachea  and  bronchi,  with  their  chief  ramifica- 
tions within  the  lung.  This  cast  shows  a  type  of  division  less  frequent  than 
the  last,  the  right  and  left  bronchi  being  at  about  a  right  angle  with  one 
another,  a.  eparterial  branch:  b.  ventral  hyparterial  branches:  h'.  accessory 
(azygos)  branch;  c,  dorsal  hyparterial  branches.  (Quain.  after  Aeby.  I 

The  angle  which  the  tube  makes  with  the  long  axis  of  the  body  is  iJO  . 
(Fig.  127.) 

Much  less  displacement  is  required  in  order  to  introduce  the  tube 
into  the  third  bronchus  of  either  side.  On  the  right,  on  account  of  the 
fact  that  the  main  bronchus  is  so  nearly  in  line  with  the  long  axis  of 


176 


OPKI-IATIVK    Sl'RliKKY    OF    THK    NOSK,    THROAT,    AND    EAK. 


the  trachea,  the  lateral  displacement  sufficient  to  bring  tlie  bronchus  to 
the  lower  lobe  into  view  is  about  1.5  cm. 

In  lower  bronchoscopy  even  less  lateral  excursion  is  necessary. 
(Fig.  128.) 

The  Interpretation  of  the  Endoscopic  Pictures. — The  greatest  dif- 


Right  recurrent laryngeal 

nerve. 
Transverse  cervical 

artery 
Right  common  carotid 

artery. 
Suprascapular  artery. 

Internal  jugular  vein. 
Pneumogastric  nerve. 
Subclavian  vein. 
Inferior  thyroid  vein. 
Phrenic  nerve. 
Left  innominate  vein 
Ascending  aorta. 
Superior  vena  cava 
Right  bronchus. 

Branch  to  superior 

lobe  of  lung. 
Upper  branch  of  right 

pulmonary  artery. 
Branch  to  middle  lobe 

of  lung 
Right  pulmonary  vein. 

Right  auricle 

Right  coronary  artery 
Thoracic  vertebra. 
Intercostal  vein. 
Intercostal  artery 
Vena  n/ygos  major. 
Intercostal  vein 
Intercostal  artery 
Intercostal  vein 
Intercostal  artery 


Thyroid  body. 
Left  recurrent  laryngeal 
nerve. 


Pneumogastric  nerve 

eft  internal  jugular 

vein. 
eft  common  carotid 

artery. 
eft  subclavian  artery 


Left  subclavian  vein 
Trachea. 

Inferior  thyroid  vein. 
Phrenic  nerve 

(hooked  aside). 

Recurrent  laryngeal 

nerve 

Pneumogastnc  nerve 
Ductus  arteriosus. 
Left  pulmonary  artery 
Pulmonary  artery 


Thoracic  duct. 
-  Thoracic  aorta 


The  arch  of  the  aorta,  witli  I  lie  pulmonary  artery  and  chief  brandies  ot 
the  aorta.  (Morris'  Anatomy  From  a  dissection  in  St.  Bartholomew's 
Hospital  Museum J 

ficulty  which  the  observer  encounters  is  to  judge  the  perspective  right- 
ly. As  lie  looks  with  one  eye  he  is  without  the  aid  of  the  parallax 
which  binocular  vision  affords  and  is  constantly  mistaking  his  dis- 


LARYNCJOSCOPY.     BHONCHOSCOI'V.     KSolMI  A<  ;os<  < » 


I 


tance.  In  the  trachea  the  observer  can  help  himself  by  counting  1  he 
rings.  In  the  main  bronchi  measurements  are  of  more  aid.  The  irreat  - 
est  lielp  of  all  is  obtained  by  laying  the  mamlrin  of  the  examin'mir  tube 
on  the  surface  of  the  chest  and  judging  the  internal  di>1anees  from 
this.  (Kit--.  IL'!).) 

Tlie  length  of  a  stenotic  area  is  hard  to  determine  by  si.irht,  and 
is  best  made  out  by  the  use  of  a  metal  olive  tipped  bougie.  Objects  at 
the  end  of  the  tube  appear  smaller  than  they  really  are.  Their  true 


Right  common  carotid  artery 
A.  carotiscommunis  dcxtra 
Innominate  artery— A.  anonym. i 
Right  aubclavian  artery 
A.  jubclavia  dextra 
Right  innominate  vein 
V.  anonyma  dextra 
Superior  vena  cava 
V.  cava  superior 
Right  bronchuf 
Bronchus  c'extcr 


Trachea 

Left  common  carotid  artery 

A.  cari'l:-;  com::ii::'.  :  ,:-:::.   ::a 
Left  Innominate  vein 


Cervical  pleura' 
Cupula  pluiir.r 

Arch  of  the  aorta 
Arcus  n'Tt.i- 

Left  bronchus 
,,  V  l;i   r.chus  bini 


Esophagus  (thoracic  portion) 

Descending  thoracic  aorta 
Aorta  descendens 

Quadrate  lobe  of  the  liver 

J.nbus  quadratus  hepatis 

Small  or  gastrohepatic 

omentum 

Lig.  hepatosastricum 
Gall-bladder 

N'csica  fclle.i       ' 

"Hepatoduodenal  ligament 

or  omentum' 
*Lig.  liepatoduodcnale 


Caudate  lobe  of  the  liver 

I'rocessus  caudatu> 

hepatis 


Mediastinal  p'.cura 
1'lcur.l  :..'     .  ,   :.::  .  : 

Pulmonary  pleura 

1'lcu:. ..]•...::.    ::.u: 


Costal  pleura 
1'lfiirac..  Ml; 


Great  or  gastrocolic 

ouicntum-    anterior 

layer. 

Great  curvature  of  the 
stomach 


Posterior  wall  of  the 
stomach 


Fig.   130. 
Showing  the   relation   of  the  trachea   to  the  great    vessels   of   the   neek.      (From   Toldt.) 

size  can  be  reckoned  mathematically,  1ml   it  is  easier  to  obtain   it  by 
measuring  a  duplicate  of  the  object.    (  Fi.ir.   !.'!(>.) 

The  Choice  of  the  Upper  or  the  Lower  Route.— For  the  he-inner 
lower  bronchoscopy  is  easier  and  safer.  In  infants  and  youim'  children 
it  is  safer  and  often  the  method  of  choice.  The  experienced  operator 
will  succeed  with  upper  bronchoscopy  where  the  novice  will  fail,  but 
it  is  well  to  try  upper  bronchoscopy  a>  a  routine  in  all  cases.  If  it  does 
not  succeed  the  operator  should  not  hesitate  to  abandon  it  for  the  lower 
route.  There  is  no  disgrace  in  so  doinu'.  It  has  been  proved  that  in 
cases  in  which  a  foreign  hody,  like  a  bean,  has  been  playing  up  and 
down  in  the  trachea  for  some  time  the  trauma  so  caused  often  produces 
spasm  or  edema  of  the  larynx,  so  that  after  upper  l>roncho>copy.  even 


OPEKATIVK    STROERY    OF    TJIK    NOSE,    T11HOAT,    AND    EAR. 


if  it  has  been  successful,  m\  emergency  tracheotomy  may  be  necessary. 
The  question  of  upper  or  lower  bronchoscopy  should  never  depend  on 
the  pride  of  the  operator  but  on  the  good  of  the  patient. 

The  Dangers  of  Bronchoscopy. — Operative  bronchoscopy  is  nat- 
urally more  dangerous  than  examinations  merely  for  diagnostic  pur- 
poses. Jackson's  statistics  of  ninety-four  cases  of  upper  and  lower 
bronchoscopy  give  a  mortality  of  two  per  cent.  The  chief  danger  of 
the  examination  is  its  length.  Under  ether  three-quarters  of  an  hour 
is  a  safe  limit.  Rather  than  prolong  the  operation  it  is  bettor  to  try 
au'ain  at  a  second  sitting.  In  one  of  Killian's  cases  of  a  foreign  body 


Larynx 


Thyroid  body  j 

Glanduia  thyrcoidta    .         ^  / 


Apex  of  the  lu 
Apc.v  pulmoni 


Right  bronchu 


Ventral  bronchial  branch 
of  the  upper  lobe 

Kami  bronch.alesventr.il 
lobi  supenoris 

Bronchial  branch  of  the  middle 
lobe  'first  ventral  hypartenal 
branch  of  the  right  bronchus  i 


.Showing    the    divisions    of    the    traclna    and     bronchi.      (From     Toldt.) 


in  the  bronchus  ten  sittings  were  required  before  the  extraction  was 
successful,  and  many  of  these  lasted  two  hours.  Briinings  gives  the 
time  of  the  ordinary  operation  as  five  to  fifteen  minutes.  Jackson  has 
reported  the  removal  of  three  tacks  in  three  minutes.  (Fig.  1  .">!.) 


LAHYNOOSCOI'Y,     I!U<  >  \C  I  lOSCOl'Y,     KSOI'JI  AIJOSCOI'V,     K'K  '. 


171) 


Asepsis.  In  bronchoscopy  flic  nioiilli  of  the  patient  should  he 
made  as  clean  as  possible.  .Jackson  advises  a  thirty  per  cent  solution 
of  alcohol  as  a  month  wash.  It;  i»'oes  without  saving  that  the  instrn- 


II 


VIII 


IX 
X 


Fig.  I:!L>. 

Showing  the  relation  of  the  main  bronchi  to  the  ribs  and  the  chest 
wall  (Anterior  view).  (From  Anatomical  Department.  Harvard  Medical 
School.) 


nients  also  should  be  clean,  (ienerally  immersion  in  seventy  per  cent 
alcohol  is  depended  upon  for  the  sterilization,  formalin  vapor  can  be 
employed  if  preferred. 


180  OPERATIVE    srHCKKY    OF    THE    NOSE,    THROAT,    AND    EAR. 

The  Size  of  the  Tubes. — Briinings  uses  tubes  of  four  sixes. 

L'l'PEIi     Bl!<>\<  IIOSC  OI'Y. 

Number  Size                                                   Age 

1      7       mm 1  to     3  years. 

11.1 7}o  mm 4    "      5 

2      8iL,   mm 4    "      9      " 

3      10       mm 9    "    14 

4      12       mm Adults     (men     and     \vonu-ni. 

LOXVKK   Buoxc  iiostoi'Y. 

Number  Size  Age 

1      7       mm 1   to     3  years. 

2     811,  mm 3    "      8      " 

3      10       mm 8    "    14      " 

4      12       mm Adults     (  men     and     women  ) . 

BRONCHOSCOPY. 

In  order  to  see  the  secondary  bronchi  the  main  bronchus  is  dis- 
located laterally  and  the  tube  brought  into  line  with  the  bronchus  to  be 
examined. 

The  patient's  head  must  be  bent  in  the  proper  manner  to  allov\ 
this  change  in  the  position  of  the  tube.  In  changing  the  position  of 
the  head  the  neck  should  not  be  held  far  backward  and  cramped  be- 
cause this  interferes  with  the  mobility  of  the  trachea  and  the  bronchi. 

As  soon  as  the  lumen  of  the  right  main  bronchus  is  entered  and 
lighted  by  the  tube,  the  observer  sees  in  the  distance  the  opening  of 
the  bronchus  to  the  lower  lobe  and  wit  hin  this  smaller  dark,  oval  patches 
which  are  the  openings  of  the  tertiary  bronchi.  .Between  these  dark 
patches  appear  the  median  septa.  The  picture  constantly  changes. 
With  every  movement  of  the  tube  new  openings  of  new  branches  come 
into  view,  in  the  depths  of  which  other  divisions  are  seen.  (Fig.  1X>.) 
In  the  deeper  bronchi  there  is  a  rhythmical  change  of  the  picture  with 
respiration. 

When  the  tube  is  placed  high  in  the  main  bronchus  the  opening  of 
the  branch  to  the  upper  lobe  as  well  as  of  that  to  the  middle  lobe  gen- 
erally are  not  seen.  It  is  only  after  inserting  the  tube  to  the  proper 
depth  and  dislocating  the  bronchus  between  one  and  one  and  five- 
tenths  cm.  to  the  side  and  upward,  that  the  lower  circumference  of  the 
opening  of  the  branch  to  the  upper  lobe  is  discovered.  If  the  manipu- 
lation is  not  successful  the  tube  is  inserted  below  the  origin  of  the  first 
branch  and  lateral  pressure  is  made  as  before  and  the  tube  withdrawn. 
As  the  tube  comes  up  the  opening  of  the  bronchus  springs  into  view. 


LAKYXdOSCOl'Y,     HHOXC  1 1  <)S(  'OI'V,     KSOPIIACOSCOI'V,     KT<  . 


1S1 


182 


OPERATIVE    SURtiKKV    OF    THE    NOSE,    THROAT,    AND    EAR. 


Fig.    I'.'A. 

Diagram  to  show  the  bronchoscopic 
picture.  (After  Jackson.) 

A.  The  bifurcation  of  the  trachea  is 
shown  to  the  left,  of  the  middle  lino.  1. 
Left  main  bronchus.  2.  Right  main 
bronchus. 

H.  I'icture  of  the  loft  main  bronchus 
(see  FJK.  128).  1.  Hronchus  to  upper 
lobe.  L'.-!!.  Mronchi  to  lower  lobe. 

('.  Picture  of  right  main  bronchus. 
1.  Hronchus  to  upper  lobe.  2.  Hronchus 
to  middle  lobe.  :',.-4.  Bronchi  to 
lower  lobe.  No.  4  is  the  practical  eon- 
lation  of  the  right  main  l)ronchus. 


Iii  lower  bronclioscopy  the 
opening  of  the  branch  to  the 
upper  lobe  is  easier  to  find.  So 
readily  can  the  opening  be  ap- 
proached that  the  circumfer- 
ence of  the  first  two  rings  can 
be  made  out.  The  field  often 
increases  rhythmically  with 
the  respiration. 

The  cavity  of  the  branch  to 
the  upper  lobe  can  be  explored 
by  placing  a  small  mirror 
through  the  examining  tube 
into  the  bronchus  or  by  insert- 
ing a  small  cystoscope.  With 
the  latter  Briinings  has  dem- 
onstrated even  the  tertiary 
bronchi.  The  cystoscope  should 
have  a  diameter  of  8  mm.  and 
if  designed  for  both  upper  and 
lower  bronclioscopy  it  should 
be  about  30  cm.  long. 

Although  cases  have  been 
reported  of  foreign  bodies 
lodged  in  the  branch  to  the  up- 
per lobe  (Wild  and  Gottstein), 
as  a  rule  such  cases  are  rare. 
Killian  calls  attention  to  the 
fact  that  Ihe  examination  of 
this  branch  might  give  a  clew 
to  tuberculosis  of  the  right 
apex,  that  is,  pus  might  be  seen 
coming  from  the  opening  of 
Ihe  bronchus  in  such  cases. 
(Fig.  134.) 

Tin?  direct  examination  of 
the  branch  to  the  middle  lobe 
is  easily  accomplished  when 
the  tube  is  carefully  introduced 
and  pressure  is  made  in  a  for- 
ward direction.  This  opening, 
however,  can  be  readily  con- 
fused with  that  of  the  branch 


LAKYNOOSCOI'Y.     BliO  N( '  1 1  OS< 'Ol' Y  ,     KS 


is;; 


to  the  lower  lobe.  In  all  cases  in  which  the  observer  is  in  doubt  tin- 
tube  should  be  withdrawn  to  the  bifurcation  and  then  carried  down- 
ward aiaun  step  by  step. 

The  branch  of  the  riu'ht   main  bronchus  to  the  lower  lobe  is  ivallv 


Fig.   135. 
Diagrammatic   drawing    to   show    the   bronchoscopic    picture   at    various   levels. 

a  continuation  of  the  main  bronchus.  For  this  reason  the  opening  of 
the  third  secondary  bronchus  is  not  only  easy  to  see  and  enter  with 
the  tube  but  this  is  the  bronchus  which  most  often  catches  foreign 
bodies.  (Fii>'.  135.) 

The  left  main  bronchus  leaves  the  trachea  much  more  sharply  than 
the  riu'ht  bronchus  does.-   For  this  reason  it  is  harder  to  u'ain  access 


184 


OPERATIVE    SfRCERY    OF    THE    NOSE,    THROAT,    AND    EAR. 


a.  .«  c 


;"   1*  =4—   S   S  i-^ 


LAUYXCOSCOI'Y,     BKONCIIOSrol'Y,     KS<  >!'  1 1  A<  i(  »S( '( >!">  .     KT<   . 


i  sr, 


t<>  it  and  to  brin.tr.  its  branches,  especially  the  lirst,  into  view.  This 
bronchus  is  easier  to  see  by  lower  bronelioseopy.  In  invot  iirat  intr  the 
left  main  bronchus  strong  pulsations  from  the  arch  of  the  aorta  are 
noticed.  (  Fitr.  l.'HJ. ) 

The  origin  of  the  branch  of  the  left  main  bronchus  to  the  upper- 
lobe  is  4-f>  cm.  from  the  bifurcation.  It  is  to  be  found  on  the 
lateral  wall  and  somewhat  anteriorly.  It  is  often  missed  both  on  the 


Fig.  137. 

Horizontal   section   of   thorax   of   man.   aged    f>7.   immediately   abov< 
bifurcation    of   the   trachea,    seen    from    above.      (From    Qnain.) 


tht 


V.  L..  upper  lobe  of  right  lung;  V.  P..  L.  L..  upper  and  lower  lobes  of  left 
lung:  II.  B.,  L.  M.,  origin  of  right  and  left  bronchi,  in  this  specimen  the  ter- 
mination of  the  trachea  was  lower  than  usual:  A.,  arch  of  aorta:  D.  A.. 
descending  aorta;  D.,  obliterated  ductus  arteriosns:  X..  left  recurrent  laryn- 
geal  nerve;  L.  G.,  lymphatic  glands;  other  letters  as  in  Fig.  1?,8. 

insertion  and  on  the  withdrawal  of  the  tube,  and  a  siirlit  of  it  is  to  be 
gained,  if  at  all,  by  strong  lateral  and  upward  dislocation  of  the  main 
bronchus  and  with  the  end  of  the  tube  held  as  obliquely  to  the  lateral 
wall  as  possible.  Naturally  foreign  bodies  do  not  often  train  entrance 
to  this  bronchus.  (Fig1.  137.) 

On  the  left  the  second  branch  of  the  main  bronchus,  the  bronchus 
to  the  lower  lobe,  is  for  all  intents  and  purposes  a  continuation  of  the 
main  bronchus.  The  tube,  therefore,  rinds  it  readily  and  the  picture 
seen  throuirh  the  tube  shows  the  lumen  of  the  third  branch  and  then 
the  division  into  the  dorsal  and  ventral  branches. 


OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 

Lower  bronchoscopy  carried  out  as  has  been  indicated  is  not  diffi- 
cult. The  bronchi  should  be  examined  both  on  the  introduction  of  the 
tube  and  on  its  withdrawal.  The  examination  cannot  be  considered 
complete  unless  both  main  bronchi,  the  secondary  bronchus  on  the  right 
to  the  middle  lobe  and  the  branch  to  the  lower  lobe  on  both  sides  have 
been  examined.  The  exploration  of  the  two  main  bronchi  and  the  branch 
to  the  lower  lobe  on  the  right  is  especially  demanded  because  foreign 
bodies  often  lodge  in  them.  In  the  author's  experience  foreign  bodies 


Fig.  138. 

Horizontal  section  of  the  thorax  of  a  man,  aged  57,  at  the  level  of  the 
roots  of  the  lungs,  seen  from  above.  (From  Quain.) 

I.  S.,  superior  and  inferior  lobes  of  lungs;  E.,  eparterial  bronchus; 
A.  M.,  anterior  mediastinum;  It.  P.  C.,  right  pleural  cavity;  P.  C.,  pericardial 
cavity;  A.  A.,  ascending  aorta;  P.  A.,  pulmonary  artery;  R.  P.  A.,  its  right 
branch;  R.  P.  V.,  L.  P.  V.,  right  and  left  pulmonary  veins;  A.  V..  a/ygos 
major  vein;  other  letters  as  in  Fig.  136. 

lodge  ol'leiiesl  at  the  bifurcation  of  the  trachea,  in  the  dilatation  where 
the  first  branch  of  the  right  main  bronchus  conies  off,  or  in  the  internal 
branch  of  the  bronchus  to  the  lower  lobe. 

The  tertiary  bronchi  arc  so  small  that  neither  the  bronchoscope 
nor  light  can  be  made  1o  enter  them.  In  such  cases  the  use  of  a  sound 
will  enable  the  operator  to  palpate  these  small  tubes  even  to  the  peri- 
phery of  the  lungs.  (Fig.  IMS.) 

Lower  bronchoscopy  is  easier  with  the  patient  in  the  sitting  posi- 
tion. It  can  and  often  is  carried  out  with  the  patient  lying  on  his  back. 


LAKYXCOSCOI'Y,     Hl{<  I  XC  1 1  OS< '( >I'Y.     KSOIM  I  A<  lOSCOl'Y  ,     KT<  . 


is; 


It  is  harder  to  >iiana,n'e  the  position  of  the  patient's  head  if  he  is  upon 
his  hack,  because  the  handle  of  the  elect  roscope  often  u'ets  in  the  way. 
(  Fi.ii1.  !.'>{).)      With  the  Jackson  tube,  however,  this  difficulty  is  not  en 
countered. 

Upper  Bronchoscopy. 

I'ppor  bronchoscopy  is  much  more    difficult    than    lower    broncho 
scopy  on   account  of  the   more  complicated   technic   required    to   insert 


Fig.  139. 

Horizontal  section  of  the  thorax  of  a  man,  aged  57,  at  the  level  of  the 
nipples,  seen  from  above.  Note  how  the  bronchi  keep  near  the  median  line. 
This  is  fortunate  in  the  removal  of  foreign  bodies.  (From  Quain.) 

«..,  nipple;  M.,  middle  lobe  of  right  lung;  R.  A.,  right  auricle:  R.  V.. 
right  ventricle;  L.  A.,  left  auricle;  L.  V.,  left  ventricle;  R.  V.  P.,  right 
posterior  valve  of  aortic  orifice;  r.  p.  <•..  right  pleural  cavity:  other  letters 
as  in  Fig.  136. 

the  brouclioscope,  due  to  the  form  of  the  larynx,  and  because  of  the 
slighter  mobility  of  the  tube  and  its  greater  length. 

Anesthesia. — The  Gorman  school  are  strong  advocates  of  local 
anesthesia  and  the  sitting  position  of  the  patient  durin.u-  the  examina- 
tion. In  this  country  general  anesthesia  is  used  laruvly  and  the  pa- 
tient is  examined  lyin^  on  his  back.  The  use  of  ether  does  away  with 
the  sense  of  hurry  which  attends  bronchoscopy  under  local  anesthesia. 

The  Method  of  Performing  Upper  Bronchoscopy. — If  local  anes- 
thesia is  to  be  employed  the  larynx  of  the  patient  is  cocainized  as  for 


188  OPERATIVE    srKdF.KY    OF    THE    NOSE,    T1LROAT,    AND    EAR. 

direct  inspection.  The  reflexes  of  the  larynx  are  the  most  active.  After 
the  anesthesia  has  been  accomplished  the  vocal  cords  are  exposed.  If 
Briinings'  instruments  are  selected,  this  is  done  with  the  tubular  spa- 
tula used  after  the  fashion  of  his  speculum,  employed  for  direct  inspec- 
tion of  the  larynx.  Jt  is  not  necessary  to  expose  the  anterior  commis- 
sure, so  that  the  operator  is  content  with  disclosing1  the  posterior 
third,  or  the  posterior  half  of  the  cords.  If  this  much  is  not  read- 
ily brought  into  view,  the  assistant  pushes  the  larynx  backward. 

The  passage  of  the  larynx  is  the  difficult  part  of  the  manipulation. 
This  is  best  accomplished  by  cautioning  the  patient  to  breathe  quietly 
and  regularly.  TVhen  he  does  this  the  cords  part  in  inspiration  and 
the  tube  is  slipped  between  them  and  into  the  trachea.  The  cords  need 
not  be  widely  separated.  Sometimes  it  is  necessary  to  turn  the  spatula- 
like,  edge  of  the  speculum  anteroposteriorly  and  to  insert  it  in  this 
manner  between  the  cords  and  then  to  turn  the  speculum  and  force  the 
cords  apart.  The  introduction  of  the  warmed  and  oiled  tube  is  brought 
about  not  so  much  by  force  as  by  manipulation  and  a  lever-like  move- 
ment of  the  tube  under  the  guidance  of  the  physician's  left  forefinger. 

The  Introduction  of  the  Bronchoscope  With  the  Patient  Lying  On 
His  Back. — Where  the  patient  is  placed  on  his  back  it  is  necessary  for 
the  introduction  of  the  tube  to  have  the  head  held  over  the  end  of  the 
table.  After  the  tubular  speculum  has  passed  the  upper  part  of  the 
epiglottis  the  head  must  be  lowered  for  the  exposure  of  the  cords  and 
the  passing  of  the  tube,  between  them. 

In  the  prone  position  of  the  patient  the  handle  of  the  electroscope 
is  somewhat  in  the  way.  This  difficulty  is  not  encountered  it'  the  .'Jack- 
son tubular  speculum  is  used  because  the  speculum  is  discarded  as 
soon  as  the  bronchoscope  has  entered  the  glottis.  If  the  introduction 
of  the  tube  is  difficult  the  patient  may  be  turned  on  his  left  side.  The 
tubular  speculum  is  then  carried  in  from  the  left  corner  of  the  mouth. 
The  head  is  unsupported.  The  speculum  easily  passes  into  the  tra- 
chea. After  the  speculum  has  entered  the  trachea  the  patient  is  turned 
upon  his  back  again  and  the  examination  completed.  The  cords  hav- 
ing been  passed  the  rest  of  the  examination  is  carried  out  as  in  lower 
bronchoscopy.  \Vhen  the  tubular  speculum  has  explored  the  trachea 
to  the  bifurcation  the  inner  tube  is  inserted  and  advanced  step  by  step 
to  the  main  bronchi.  Naturally  it  is  not  possible  to  move  a  tube  when 
passed  from  the  month  as  much  as  a  tube  introduced  through  a  trache- 
otomy wound.  Therefore  there  is  less  lateral  dislocation  of  the  trachea 
and  the  bronchi.  To  make  up  for  this  loss  the  alteration  or  moulding 
of  the  patient's  body,  chielly  the  position  of  his  spine,  is  called  into 
play.  The  bronehoscope  is  shifted  to  the  corner  of  the  mouth. 


LAIIYXOOSCOI'Y,     I1IIO  \< '  1 1  OS< 'Ol'Y  ,     KSO|'HA(,os<  ol'Y,     K'I'C.  1s!' 

Upper  Bronchoscopy  with  the  Jackson  Tubular  Speculum  and  the 
Jackson  Bronchoscope.  The  tubular  speculum  of  .Jackson  is  very  con 
venient  for  exposing  the  larynx  and  for  introducing  the  bronchoseope. 
Jackson  until  recently  has  preferred  to  pass  the  bronchoscope  under 
U'eiieral  anesthesia  and  with  the  patient  lyinu'  on  his  hack.  Lately  lie 
has  discarded  both  local  and  .u'cneral  anesthesia.  The  experience  of  the 
writer  of  this  article  has  been  obtained  almost  wholly  with  irencral 
anesthetics.  After  the  cords  have  been  exposed  with  the  tubular  spec 
iiliiin  a  bronchoscope  of  the  selfdi^htiu.u'  pattern  and  of  appropriate 
size  is  passed  through  the  speculum  and  between  the  cords.  Then  the 
separable  hood  is  removed  and  the  speculum  withdrawn. 

The  Introduction  of  the  Bronchoscope  with  the  Open  Speculum. 
-The   introduction   of  the   bronchoscope     with     the    adjustable     open 
speculum  of  the  author  is  the  simplest   method  of  passing  the  hroncho- 
scope  under  vision. 

The  Examination  in  Children. 

Owinii1  to  the  flexibility  of  the  neck  in  the  child  and  to  the  shorter 
distances,  the  direct  inspection  of  the  larynx  in  infants  and  children 
is  often  comparatively  easy.  The  structures  are  diminutive  so  thai  the 
field  obtained  is  small.  The  epiglottis  is  undeveloped  and  often  very 
unruly  when  the  speculum  attempts  to  control  it. 

The  difficulties  in  the  examination  of  children  arise  from  the 
smallness  of  the  structures  which  necessitates  tubes  as  small  as  (i-7  mm. 
Through  these  it  is  hard  to  i>'ot  a  ,n'ood  view  and  to  manipulate  instru- 
ments. In  addition  the  examiner's  difficulties  are  increased  by  the 
unruliuess  of  the  patient,  by  the  tendency  to  spasm,  by  salivation,  by 
the  strong  respiratory  movements  of  the  trachea  and  the  bronchi,  and 
lastly  by  the  greater  tendency  to  collapse  either  with  local  or  general 
anesthesia. 

In  most  cases  bronchoscopy  is  undertaken  in  children  for  the  de- 
tection and  the  removal  of  foreign  bodies.  Foreign  bodies  are  most 
common  in  children,  to  summarize  a  table  from  Gottstein,  between  the 
second  and  the  sixth  year.  Sixty-nine  per  cent  of  cases  occur  before 
the  twelfth  year,  and  only  thirty-eiii'ht  per  cent  from  the  twelfth  year 
onward. 

Instruments. — "Relatively  wider  specula  may  be  used  in  children 
than  in  adults.  Forceps  and  all  other  instruments  which  are  to  be  used 
through  the  diminutive  tubes  which  are  employed  in  children  must  be 
especially  small  in  calibre.  Briininju's  has  a  special  form  of  electroscope 
which  lie  advises  for  this  work.  Other  instruments  are  the  open  spec- 
ulum of  Briiuhiii's,  or  that  of  the  writer.  A  self -lighted  uretlirascope 


190  OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 

is  of  service  for  use  through  a  tracheotomy  wound.  The  size  of  such 
tubes  varies  between  7  and  8  mm.  The  sizes  of  the  urethrascopes 
should  be  5,  6,  and  8  mm.  Seventeen  cm.  is  a  sufficient  length  for  the 
forceps. 

Direct  Laryngoscopy. — The  simplest  way  to  examine  a  baby  is  to 
wrap  it  in  a  blanket  and  to  place  it  on  its  back  on  a  table  and  expose 
the  larynx  with  the  open  speculum  or  the  children's  size  of  the  .lack- 
son  speculum.  The  examination  of  the  child  held  in  a  sitting  posture 
in  the  arms  of  a  nurse  is  also  satisfactory.  For  this  purpose  the  spec- 
ulum is  passed  along  the  center  of  the  tongue  or  introduced  from  the 
corner  of  the  mouth.  In  infants  and  children  the  author  lias  had  no 
experience  with  local  anesthesia.  lie  prefers  to  use  general  anesthe- 
sia. Briinings  gives  the  impression  that  examinations  conducted  in 
this  way  are  less  satisfactory  than  when  local  anesthesia  is  employed. 
It  is  doubtful  if  the  experience  of  operators  in  this  country  accords 
with  that  of  Briinings. 

The  Method  of  Examination. — The  method  of  making  the  direct 
inspection  of  the  larynx  in  infants  and  children  is  the  same  as  in  adults. 
The  distances  are  very  short  and  the  epiglottis  is  placed  high  so  that 
only  a  slight  depression  of  the  tongue  is  required  to  expose  it.  The 
pharynx  and  even  the  glottis  often  close  in  a  sphincter-like  fashion, 
and  from  tiine  to  time  the  whole  working  field  is  flooded  with  mucus. 
A  speculum  with  a  broad  end  is  especially  serviceable  in  raising  the 
stubby  and  elusive  epiglottis.  Often  the  anterior  commissure  of  the 
larynx  can  be  moulded  into  view  by  external  pressure.  In  holding  the 
head  it  should  not  be  bent  too  far  backward. 

Lower  Bronchoscopy. —  Lower  bronchoscopy  is  carried  out  with 
children  in  Ihe  same  manner  as  in  adults.  For  the  examination  of  the 
trachea  in  the  neighborhood  of  the  fistula  the  urethrascope  or  a  small 
bronchoscope  constructed  on  this  pattern  is  of  service.  In  examining 
the  trachea  and  the  bronchi  the  respiratory  movements  of  the  air  pas- 
sages are  a  great  annoyance.  Jn  strong  respiration  the  field  may  be 
lost  altogether.  This  is  embarrassing  in  the  bronchi  because  if  the 
mucous  membrane  is  swollen  it  is  only  during  inspiration  thai  a  view 
can  be  obtained. 

Upper   Bronchoscopy.      I'pper   bronchoscopy    in    children     is    the 
most  difficult  feat  which  is  attempted  with  this  procedure.     The  exam 
iner  should  be  ready  and  willing  at  any  moment  to  supplant  it  by  lower 
bronchoscopy. 

The  author  has  had  most  experience  with  upper  bronchoscopv 
performed  under  general  anesthesia.  Small  doses  of  alropin  control 
the  secretions.  The  introduction  of  the  tube  is  easily  accomplished  in 


LARYXOOSCOl'V,     BRONC'IIOSCOPV.     KSOI'HAOOSCOI'Y,     I.'K  . 


the  usual  case  with  the  small  Jackson  speculum  or  with  the  adjustable; 
open  speculum.  Ipper  brouehoscopy  in  children  should  never  be  at- 
tempted without  instruments  and  assistants  enough  for  the  execution 
of  a  rapid  tracheotomy.  The  danger  of  subglottic  swelling  after 
bronclioscopy  in  children  should  always  be  in  the  mind  of  the  operator. 
The  patient  may  require  an  emergency  tracheotomy  not  only  durintr 
the  operation  but  at  any  time  during  the  next  day  or  two. 

The  general  conduct  of  the  examination    by  the    upper    route    is 
along  the  same  lines  as  the  examination  in  the  adult. 

Instruments  for  Bronchoscopy. 

The  essential  instrument  for  the 
performance  of  direct  inspection  of 
the  larynx,  the  trachea,  and  the  bron- 
chi, is  a  metal  tube  of  appropriate  size 
and  length.  For  direct  examination 
of  the  larynx  the  tubular  speculum  is 
constructed  so  that  it  is  open  for  a 
part  of  its  length.  For  the  examina- 
tion of  the  bronchi  the  speculum  be- 
comes a  long  tube.  The  speculum  and 
the  long  tube  can  be  lighted  from 
within  or  from  without.  The  simplest 
method  of  lighting  the  broiichoscopc 
is  that  popularized  by  Jackson.  A 
small  secondary  tube  is  carried  along 
the  side  of  the  larger  and  the  main 
tube  to  its  lower  end.  At  this  point  a 
window  turns  the  lumen  of  both  tubes 
into  one.  Tn  the  secondary  tube  a 
small  rod-like  tube  acts  as  a  carrier 
for  a  diminutive  electric  lamp.  TVhen 
the  carrier  is  in  position  the  lamp  lies  opposite  the  window  and  when 
the  lamp  is  burning  its  light  illuminates  not  only  the  end  of  the  larger 
tube  but  shines  ahead  of  it. 

The  illumination  of  the  tube  by  the  second  method  is  accomplished 
by  attaching  to  a  handle  which  can  hold  various  sizes  of  tubes,  a  small 
but  powerful  electric  lam]).  (Fig.  140.)  Above  this  a  mirror  is  so  placed 
that  the  light  from  the  lamp  is  thrown  down  and  through  the  tube. 
Briinings  has  developed  this  form  of  illumination  to  a  high  degree  of 
efficiency  in  his  various  forms  of  electroscopes.  Both  methods  of 
liii'htinir  the  examining  tubes  are  highlv  successful.  Kadi  has  certain 


19_!  OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

advantages.  The  examiner  should  provide  himself  with  both  sets  of 
instruments.  lie  certainly  should  not  allow  himself  to  become  so  pre- 
judiced as  to  lie  willing  to  use  but  one  pattern. 

The  disadvantage  of  the  self-illuminated  tube  is  that  the  light  is 
liable  to  become  clouded  with  secretions  and  blood.  It  is  surprising, 
however,  especially  if  the  examination  is  conducted  under  general 
anesthesia  and  the  secretions  controlled  by  atropin,  how  long  the  light 
will  burn  before  it  becomes  dimmed.  As  a  rule  suction  will  keep  it 
clean.  Theoretically  a  strong  case  can  be  made  out  against  the  self- 
lighted  tube  in  the  presence  of  abundant  secretion,  especially  blood, 
but  the  results  of  practical  work  refute  most  of  the  objections.  The  lights 
call  for  a  little  more  care  than  the  larger  lamp  of  the  Briinings  electro- 
scope. The  thread  of  the  small  lamp  and  the  thread  in  the  light  car- 
rier should  be  carefully  standardized  so  that  new  lamps  will  fit  and 
burn.  If  this  detail  is  attended  to,  the  small  lamps  give  almost  no 
trouble.  The  great  advantage  of  the  self-lighted  tube  is  that  its  han- 
dle is  not  complicated  and  so  at  times  in  the  way,  and  that  the  eye  of 
the  observer  has  the  full  diameter  of  the  tube  to  look  and  work  through 
from  the  beginning  of  the  tube  to  its  end.  This  reduces  the  eye  strain 
—the  physician's  eyes  are  his  capital. 

The  advantage  of  illuminating  the  tube  by  reflecting  light  through 
it  is  that  the  illumination  is  never  lost  in  the  presence  of  secretions.  A 
candid  observer  must  admit,  however,  that  it  is  more  tiring  to  look 
through  the  narrow  slit  in  the  mirror  of  the  electroscope  than  it  is  to 
look  through  the  full  lumen  of  the  self-lighted  tube.  The  author  has 
read  the  discussions  which  deal  with  the  question  of  lighting  from  the 
standpoint  of  optics,  but  has  settled  the  question  for  himself  at  the 
examining  1able.  The  beginner  in  bronchoscopy  is  advised  to  do  the 
same. 

The  Jackson  Tubular  Speculum. — The  .Jackson  tubular  speculum  is 
shown  in  Fig.  11-5.  This  speculum  is  made  in  two  sixes,  the  larger  for 
adults  and  the  smaller  one  for  infants  and  children.  The  cut  makes 
detailed  description  of  the  instrument  unnecessary. 

Johnston  has  modified  the  Jackson  speculum  by  making  the  handle 
detachable. 

The  hriinings  electroscope  is  shown  in  Fig.  140.  It  is  made  in  at 
least  three  patterns.  The  author  has  found  it  necessary  to  provide 
himself  so  far  with  but  one  pattern. 

The  Brunings  Elongating  Bronchoscope.  The  main  tube  is  a  long 
tubular  speculum.  This  is  used  to  examine  the  trachea  as  far  as  the 
bifurcation  and  the  esophagus  as  far  as  the  arch  of  the  aorta.  For  ex- 


LARYNGOSCOPY,    BRONCHOSCOl'Y,     KSOLMI  A<;os< '< »I'Y,     KTC. 


animation  beyond  these  depths  a  smaller  tube  is  fitted  into  the  larger 
one  and  carried  down  and  beyond  it  by  means  of  a  stout  spring.  By 
this  device  the  tube  can  be  lengthened  at  will.  This  form  of  tube  is 
('specially  useful  in  examinations  performed  under  local  anesthesia. 


The  Brunings  Elongating 
principle1  of  the  elongating  tube  t 
of  forceps  is  very  useful  espe- 
cially as  the  shaft  is  fitted  with 
tips  adapted  for  all  necessary  ma- 
nipulations. The  operator  should 
supply  himself  with  a  liberal  as- 
sortment. It  is  vital  to  have  a 
U'ood  tip  for  iiTaspinu',  a  tip  made 
in  the  form  of  a  punch,  and  a  tip 
of  the  proper  form  for  seixinu' 
beans  and  other  seeds.  Special 
cases  call  for  special  instruments. 

Batteries. -- The  lamp  in  the 
Jackson  speculum  and  broncho- 
scope  is  most  conveniently  light- 
ed by  a  current  obtained  from  dry 
cells.  .Jackson  employs  a  double 
battery.  .After  considerable  ex- 
perimenting the  writer  has  found 
four  dry  cells  controlled  by  a 
small  rheostat  the  most  portable, 
the  easiest  to  renew  and  alto- 
gether the  most  satisfactory. 
(  IMU'.  141.)  There  are  many 
forms  of  rheostats  with  which 
the  ordinary  street  current  can  be 
used.  These,  however,  are  too 
bulky  to  carry  about.  The  light 
in  Briinings'  electroscope  calls 
for  a  reasonably  powerful  wall 
rheostat,  such  as  is  found  in  the 
equipment  of  the  ordinary  oper- 
ating room. 

Aspirator  for  Removing  Secre- 
tions.--The  Jackson  broncho- 
scope  has  in  addition  to  the  sec- 


Forceps.-    Briinings    has   applied    the 
o  his  forceps.  (  Fiii'.   14*.)     This  form 


Fig.  141. 
Rheostat    and    battery. 

The  author  has  found  the  small  de- 
tached rheostat  and  four  dry  cells  united 
as  a  unit  the  simplest  way  of  obtaining 
the  current  to  run  the  lamp  of  the  bron- 
choscope.  The  batteries  are  easily  obtained 
and  readily  connected  with  the  rheostat. 
Batteries  that  come  in  rases  often  have 
to  be  sent  to  special  dealers  for  refilling, 
so  that  there  is  delay  in  getting  them. 

In  carrying  a  battery  of  this  kind  it  is 
necessary  to  see  that  it  does  not  become 
short-circuited  in  the  instrument  bag  and 
its  power  exhausted.  An  amperemeter 
is  used  to  test  the  battery  before  it  is 
used.  The  physician  always  knows  whether 
or  not  there  is  sufficient  current. 


194 


OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AXD    EAR. 


ondary  tube  which  curries  the  lii»'ht  u  second  uuxiliury  tube  for  the 
removal  of  secretions.  A  hund  bull)  may  be  used  attached  to  the  suc- 
tion tube  or  an  apparatus  such  us  in  employed  for  removing  fluid  from 
the  chest,  oi'  best  of  all  an  aspirator  run  by  electricity.  Small  amounts 
of  secretion  are  removed  by  folded  .u'uuze  swabs.  The  Cooliduv  cotton 
carrier  is  excellent  for  this  purpose.  (Fiir.  142.)  In  direct  examina- 
tions of  the  larynx,  long  angular  forceps,  the  blades  of  which  lock 


Fig.   142. 
Coolidge's  cotton  carrier. 


Angular  forceps  for  use  with  the  adjustable  specu- 
lum. The  forceps  are  employed  chiefly  for  sponging  with 
cotton  or  gauze,  but  are  extremely  useful  for  extracting 
foreign  bodies  from  the  mouth  of  the  esophagus.  They 
can  also  be  used  for  removing  intubation  tubes.  The 
author  uses  this  instrument  for  cocainizing  the  pharynx 
and  larynx  preliminary  to  direct  examination  of  the 
larynx,  or  osophagoscopy  or  bronchoscopy. 


Moslier's  alligator  forceps.  These  forceps  have  locking  han- 
dles so  that  the  blades  hold  firmly  whatever  they  grasp.  They 
are  made  in  two  lengths.  The  shorter  length  is  useful  for 
direct  work  upon  the  larynx,  and  the  longer  (14  inches)  is 
very  convenient  for  carrying  cotton  for  swabbing  out  the 
shorter  esophagoscope.  It  is  much  easier  to  load  this  forceps 
with  cotton  than  the  usual  cotton  carrier. 


f  Fig.  14.'!),  are  useful  for  removing  the  thick  secretions  in  the  pharynx. 
Long  alligator  forceps  (Fig.  144),  also  with  handles  which  lock',  are  a 
luxiirv  when  short  tubes  are  used  because  it  is  very  easy  to  replace  the 
swabs.  (  Figs.  14.")  and  14(i.) 

Acquiring  Skill.  15 r finings  in  his  course  to  students  drills  t  he  men 
in  the  extraction  of  foreign  bodies  placed  in  a  rubber  maimikin  of  the 
respiratory  tract.  Practice  of  this  kind  is  very  valuable.  l>y  it  the 
beginner  |earn>  to  see,  and  learns  the  best  wav  of  using  the  different 


LAHYNOOSCOI'Y,     15KONC '  1 1  OS< 'Ol  >Y  ,     KSI »!'  1 1  A< ,( )SC(  >l"i  ,     KTC. 


I!).') 


kinds  of  force) >s.  If  Killian's  inainiikhi  (  Fi,n'.  14<  )  is  not  at  hand  much 
the  same  kind  of  practice  can  lie  obtained  if  a  foreign  body  is  placed 
in  a  rubber  tube.  Foreign  bodies  may  bo  placed  in  tlie  air  passages  of 
narcoti/cd  doi^s.  The  cadaver  used  for  bronchoscopy  u'ives  both  prac- 
tice  in  removing  foreign  bodies  and  what  is  even  more  important,  a 


Fig.    14; 


Jackson's  tube  forceps.  ]?,  actual  size  of  tube  and  jaws  of  forceps ;  [) 
and  K,  dilators  for  bronchoscopic  strictures,  which  can  be  used  in  con- 
nection with  Jackson's  tube  forceps  handle. 


Fig.    146. 
t'oolidiio's  forceps 


knowledge  of  the  applied  anatomy  of  the  bronchial  tree.  The  \)\->{ 
practice  of  all  is  afforded  by  an  adult  patient  wearing  a  tracheotomy 
tube  if  the  physician  is  fortunate  enough  to  tind  such  a  patient  \vh<>  is 
willinu1  to  make  capital  of  his  infirmity. 

If  the  physician  who  undertakes  bronchoscopy  or  osophaii'oscopy 
is  mechanical,  and,  in  addition,  lias  or  will  ac<|iiire  an  elementary 
knowledge  of  applied  electricity,  many  difficulties  in  his  ne\v  work  will 
be  easily  overcome.  Jackson  is  fond  of  saying,  and  saying  it  in  his 
forcible  way,  that  the  extraction  of  foreign  bodies  is  purely  a  matter  of 
mechanical  skill.  Inborn  skill,  however,  can  be  offset  and  sometimes 
surpassed  by  the  skill  which  comes  from  willingness  to  learr  and  at- 


JlH)  OPERATIVE    SUKCEKV    OF    THE    NOSE,    THROAT,    AND    EAR. 

tention  to  detail.  And  the  details  of  instruments  and  instrumentation 
in  bronchoscopy  are  many.  The  physician  who  is  not  willing,'  to  deal 
with  these  petty  details  is  happier  out  of  this  kind  of  work.  The  moral 
of  this  little  preachment  is — learn  your  instruments,  how  they  are 
made,  how  they  should  work,  and  how  they  are  to  be  kept  in  order, 
"(iridlev  vou  may  fire  when  ready."  Von  must  be  Gridley. 


Kig.  147. 
Killian's     manikin     for     practicing     bronchoscopy   and   esophagoscopy. 

Direct  Laryngoscopy  for  Diseased  Conditions. 

Malignant  Disease. — Malignant  disease  often  calls  for  the  direct 
examination  of  the  larynx  in  order  to  obtain  a  clear  view  of  the  growth, 
and  especially  to  secure  the  removal  of  a  satisfactory  specimen.  l>y  the 
use  of  a  ii'ood  punch  forceps  (  Fiu'.  14."))  this  can  be  taken  from  the  most 
favorable  place,  that  is,  from  the  mar.u'in  of  the  uro\vt  h  so  that  the 
di>ea>ed  and  healthy  tissue  appear  side  by  side.  In  small  growths 
direct  la  rvnu'oscopv  and  direct  instrumentation  should  not  be  depended 
upon  for  a  cure  the  larynx  should  be  opened  from  the  outside;  but  in 


LARYXOOSCOPY,    BRONCHOSCOPY,    ESOI'II  A<  lOSCOl'V,     KTC. 


197 


IKe 
(-X- 


advancod  and  inoperable  malignant  disease  palliative  procedures 
the  removal  of  obstructing  masses  are  justifiable  and  are  easil\ 
edited.  (Figs.  148-150.) 

Non-Malignant  Disease  of  the  Larynx. — Benign  neoplasms  of  the 
larynx  offer  a  wide  field  for  the  employment  of  direct  laryngoscopy. 
Chief  among  these  tumors  are  papillomata.  In  the  experience  of  the 
writer  the  removal  of  papillomata  under  local  anesthesia  has  not  been 
successful.  Even  witb  the  use  of  a  general  anesthetic  and  with  the 
patient  lying  on  his  back  the  procedure  is  not  always  a  calm  one  or 


Fig.   148. 
Br iinings    elongating    forceps. 


Fig.  149. 

Tips  for  Briinings 
forceps. 


Expanding  tip 
for  Briinings  forceps. 


fully  satisfactory.  Direct  laryngoscopy,  however,  is  by  far  the  best 
method  of  conducting  the  removal  of  these  luxuriant  and  recurring 
growths.  The  management  of  these  cases  advocated  by  Clark  is  the 
one  followed  by  the  author.  The  child  is  examined  under  ether  by  the 
direct  method,  and  if  there  is  an  abundant  growth  tracheotomy  is  per- 
formed. Then  the  larynx  is  freed  from  papillomata  by  using  appro- 
priate instruments  through  the  Jackson  speculum  or  the  open  specu- 
lum. Where  the  vestibule  of  the  larynx  is  nearly  choked  with  the 
growth  Mosher's  spiral  wire  forceps  (Fig.  151)  will  quickly  remove  a 
large  amount  and  allow  the  remaining  masses  to  be  dealt  with  leisurelv 


L98 


OPERATIVE    SURGERY    OF    THE    XOSE,    THJ10AT,    AND    EAR. 


and  with  the  same  instrument.  The  spiral  wire  forceps  comes  up  with 
papillomata  l)etweou  the  various  wires  like  a  fish  net  filled  with 
fish.  It  is  important  in  removing  papillomata  to  wound  the 
normal  mucous  membrane  as  little  as  possible  because  each  abrasion 
is  almost  sure  to  have  the  growth  transplanted  upon  it.  When  the 
papilloma  is  placed  well  forward  on  the  cord  or  in  the  anterior  coin- 


Fig.  151. 
Mosher's    spiral    wire    forceps    for    removing    papilloma    of    the    larynx. 

missure  it  is  often  very  hard  to  expose  even  under  general  anesthesia. 
In  such  cases  the  triangular  guillotine  tube  is  useful  for  securing  it. 
(  Pig.  152.) 

It  lias  been  the  experience  of  Clark  that  after  a  child  has  worn  the 
tracheotomy  tube  a  year  or  more  the  papillomata  shrink  markedly 
and  in  time  disappear.  At  appropriate  intervals  the  child  is  etherized 


Fig.   ir,L>. 

Mosher's  triangular  fenestrated  tube.  Used  for  the  removal  of  peduncu- 
late, d  growths  from  the  vocal  cords.  It  is  especially  useful  when  the  growth 
springs  from  the  anterior  commissure.  In  use  the  growth  falls  through 
the  window  of  the  tube  and  is  cut  off  by  forcing  home  the  plunger  which 
has  a  cutting  edge  and  acts  as  a  guillotine. 

again  and  the  remaining  growths  thinned  out  or  eradicated.  Some 
operators  like  Jackson' do  not  practice  tracheotomy  in  cases  of  papil- 
lomata but  follow  the  growths  through  the  cords  into  the  trachea  even 
without  the  safeguard  of  this  procedure.  An  emergency  tracheotomy, 
however,  may  be  called  for  at  any  moment.  This  operation  can  be 
taken  out  of  the  emergency  class  and  performed  at  the  leisure  of  the 
operator  if  the  patient  is  given  air  by  intubing  the  larynx  and  trachea 
with  a  small  bronchoscope.  The  author  has  made  for  this  purpose  the 
small  instrument  shown  in  Km'.  1 .").'!  which  he  carries  with  his  traclie- 


LAHYXOOSCOI'Y,     KKOXCIIOSCOI'Y,     KSOI'II  AliOSCOI'Y,     KTC. 

otoiny  set.  It  is  small  enough  to  pass  into  any  larynx  and  long  enough 
to  go  well  down  the  trachea.  It  is  fitted  with  a  plunger  so  that  very 
little  exposure  of  the  larynx  is  necessary  for  its  quick  introduction. 
There  are  breathing  holes  on  the  sides  near  the  lower  end.  To  have 
this  simple  instrument  always  at  hand  is  a  great  comfort.  It  can  he 
used  with  adults  as  well  as  with  children. 

Harris  lias  lately  reported  the  disappearance  of  a  papilloma  under 
radium. 

Other  benign  neoplasms  occur,  and  these,  just  as  papillomata,  arc- 
best  dealt  with  by  direct  laryngoscopy.  Among  these  are  fibromata, 
lipomata,  cysts  and  edematous  polypi.  Singers'  nodes  might  be  treated 
bv  this  method  should  removal  be  advisable. 


Pig.  153. 

Small  bronchoscope  for  emergency  intubation  which  the  author  always 
carries  in  his  kit.  By  means  of  it  intubation  can  be  quickly  performed. 
The  instrument  is  small  enough  for  a  child's  larynx.  By  using  an  instru- 
ment of  this  kind  many  emergency  tracheotomies  can  be  avoided.  If  a 
tracheotomy  becomes  necessary,  the  procedure  is  made  simple  and  easy,  be- 
cause the  patient  breathes  through  the  bronchoscope  and  the  opening  of 
the  trachea  can  be  done  calmly  and  without  hurry.  In  many  instances 
familiarity  with  such  a  preliminary  intubation  would  be  a  great  help  to  the 
general  surgeon. 

Tuberculosis  of  the  Larynx. — When  tuberculosis  of  the  larynx 
calls  for  surgical  treatment  direct  operating  is  most  satisfactory. 

Inflammatory  Diseases. — In  infections  of  the  pharynx  accompa- 
nied by  edema  or  abscess  the  patient  can  be  relieved  by  direct  laryn- 
goscopy and  direct  treatment  and  many  a  tracheotomy  averted. 

Malformations  of  the  Larynx,  Congenital  and  Acquired. — Congen- 
ital webs  of  the  larynx  are  easy  to  make  out  and  to  treat  by  the  direct 
method.  An  appropriate  speculum  and  a  long  laryngeal  knife  are  the 
only  instruments  usually  needed. 

After  diphtheria,  especially  when  it  has  been  necessary  to  intube 
often,  the  cords  may  glue  together  for  a  certain  part  of  their  length. 
Generally  the  anterior  third  or  two-thirds  of  the  inner  surfaces  of  the 
cords  adhere.  Such  cases  can  be  managed  by  prolonged  intubation 
with  large  tubes  of  the  Kodgers  pattern.  The  cords  must  be  first  sep- 
arated. This  is  done  either  with  an  Otis  nrethrotome  or  with  the  laryn- 
geal knife.  Then  the  aperture  of  the  glottis  and  the  region  below,  for 
the  subglottic  portion  of  the  larynx  is  narrowed  also,  is  stretched  with 
the  dilating  mechanism  of  the  urethrotome  or  better  with  a  dilator 
constructed  on  the  pattern  of  Kollman.  As  the  Kodgers  tube  is  con- 
ical and  tends  to  slip  out  of  the  larynx  it  is  retained  by  a  clasp  inserted 


OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

and  worn  through  a  permanent  tracheotomy  wound.  For  dilating  the 
cavity  of  the  larynx  male  nrethral  sounds  may  be  passed  through  the 
tracheotomy  wound  upward  into  the  larynx.  Naturally  the  operative 
procedures  are  carried  out  by  direct  laryngoscopy.  The  insertion  of 
the  tube  is  most  conveniently  performed  by  direct  intubation.  In  this 
country  Wilson  was  the  first  to  bring  direct  intubation  before  the  pro- 
fession. The  author  has  devised  a  set  of  instruments  for  handling  the 
tubes.  The  author  also  has  used  direct  inspection  a  few  times  for  the 
detection  of  laryngeal  diphtheria,  the  removal  of  loose  membrane  and 
immediate  intubation.  Direct  inspection  generally  makes  the  waiting 
for  the  microscopic  report  of  a  culture  unnecessary.  It  is  a  great  satis- 
faction to  look  down  and  to  see  the  membrane  and  to  take  the  case  out 
of  the  emergency  class  then  and  there  by  intubation. 

Retrograde  Laryngoscopy. 

Retrograde  laryngoscopy  is  the  name  given  to  the  examination  of 
the  larynx  from  below  by  means  of  a  tracheoscope  introduced  through 
a  tracheotomy  wound.  This  method  may  give  valuable  information. 
The  tracheoscope  should  be  f)  mm.  in  diameter  and  14  cm.  long  for  a 
child,  and  S  mm.  wide  and  20  cm.  in  length  for  an  adult.  (Jackson.) 

Tracheobronchoscopy  in  Diseases  of  the  Trachea  and  Bronchi. 

Diseases  of  the  trachea  and  the  bronchi  which  call  for  broncho- 
scopy  are  divided  into  stenotic  and  non-stenotic. 

Since  the  advent  of  bronchoscopy  many  cases  considered  as  ner- 
vous cough  have  been  found  on  examination  by  tracheobronchos- 
copy  to  be  due  to  visible  and  curable  lesions.  Bronchoscopy  was  given 
its  first  great  impetus  when  it  was  proved  that  it  is  possible  to  remove 
by  its  aid  foreign  bodies  lodged  in  the  trachea  and  bronchi.  This  field 
has  been  well  exploited.  In  this  country  at  least,  but  little  work  has 
been  done  with  it  in  the  various  diseases  \vhich  can  be  disclosed  and 
treated  by  it.  in  the  near  future  there  should  be  a  great  advance  in 
this  line.  Kor  the  fullest  knowledge  that  we  have  on  this  subject  the 
reader  is  referred  to  the  book  of  von  Schroetter.  lacerations  near  the 
bifurcation  of  the  trachea  which  were  causing  chronic  cough  have  been 
found  repeatedly  and  cured  by  applications. 

('hronic  catarrhal  inflammation  of  the  trachea  which  does  not 
yield  to  the  usual  forms  of  treatment  justifies  direct  examination  and 
treatment. 

As  a  surgical  feat  which  as  yet  has  not  been  duplicated  many  times, 
hut  which  may  at  any  moment  become  a  common  procedure,  the  finding 
of  pus  near  the  periphery  of  the  lung  may  be  mentioned.  Abscess  of 
the  limn'  due  to  a  foreign  body  can  be  localized  by  the  bronchoscope 


LAKYMJOSCOI'Y,    BUONTIIOSCOI'Y,     KS(  )l'l  I  A<  i<  >S( '( >!">  ,     KTC.  201 

and  il'  the  foreign  body  cannot  be  secured  through  the  tube,  the  tube, 
or  a  probe  passed  through  il  can  be  used  as  a  guide  to  the  surgeon  cut- 
ting from  the  outside. 

Stenosis  of  the  Trachea. —  Neighboring  organs  not  infrequently 
press  upon  the  trachea  and  cause  its  partial  occlusion.  The  thyroid 
gland  is  a  frequent  offender.  As  a  rule  it  presses  backward  and  since 
one  lobe  is  generally  more  enlarged  than  the  other  the  resulting  nar- 
rowing of  the  trachea  occurs  in  the  anteroposterior  direction  and 
somewhat  laterally.  When  the  retrotracheal  portion  of  the  gland  as 
well  as  the  anterior  part  enlarges  the  trachea  becomes  a  narrow  oval 
slit,  the  "scabbard"  trachea. 

It  has  been  denied  that  enlargement  of  the  t  hymns  could  produce 
difficulty  in  breathing,  the  so-called  thymic  asthma.  .Jackson  reports 
a  striking  case  in  which  the  condition  was  present.  When  the  case  was 
seen  it  demanded  an  immediate  tracheotomy.  This  did  not  relieve  the 
dyspnea.  The  passage  of  the  tracheoscope  showed  that  the  trachea  be- 
low the  incision  was  flattened  almost  to  complete  closure  from  before 
backward,  but  the  insertion  of  a  long  tracheotomy  tube  finally  relieved 
this  dyspnea  and  then  the  gland  was  removed,  the  case  resulting  in  a 
cure.  Tubercular  glands,  especially  those  at  the  bifurcation  of  the  tra- 
chea, malignant  disease  of  the  esophagus  or  of  the  mediastinum,  and 
aneurism  often  narrow  the  lumen  of  the  trachea  or  of  the  primary 
bronchi.  The  diagnosis  of  these  conditions  may  be  confirmed  or  estab- 
lished by  bronchoscopy. 

Jackson  gives  the  following  table  of  diseases  of  the  walls  of  the 
trachea  and  the  bronchi  which  cause  stenosis: 
Malignant  neoplasms. 
Benign  neoplasms. 
.').     Specific  inflammations. 

(a)  Syphilis. 

(b)  Tuberculosis. 

(c)  Glanders. 

(d)  Typhoid  fever. 

(e)  Diphtheria. 

4.  Inflammations. 

(a)  "Catarrhal." 

(b)  Irritative. 

(c)  Traumatic. 

(d)  Operative. 

(e)  Post-operative. 

5.  Post  inflammatory  conditions  as  cicatrices,  and  adhesions. 
().     Yasomotor   disturbances,    angioneurotic   edema. 


202  OPERATIVE    STROERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

Benign  neoplasms  are  not  frequent  but  when  they  are  present  they 
are  well  adapted  for  removal  through  the  bronchoscope.  In  asthma 
sensitive  areas  have  been  found  in  the  trachea  and  bronchi  and  appli- 
cations made  to  them  gave  relief.  Syphilis  is  the  most  frequent  cause 
of  stenosis.  Xext  come  the  narrowings  caused  by  the  healed  ulcers  of 
diphtheria  or  of  typhoid  fever.  Stricture  of  the  bronchi  from  similar 
causes  is  occasionally  seen. 

Treatment. — The  treatment  of  stricture  of  the  larynx  by  prolonged 
intubation  has  been  described.  Strictures  of  the  cervical  portion  of  the 
trachea  associated  with  loss  of  the  cartilaginous  rings  are  probably  best 
treated  by  plastic  surgery  which  aims  at  holding  the  trachea  open  by 
the  transplantation  of  some  rigid  material.  The  success  of  the  trans- 
plantation of  cartilage  for  the  correction  of  nasal  deformity  may  open 
ii])  a  method  of  dealing  witli  these  cases  of  tracheal  stenosis  combined 
with  loss  of  cartilage. 

The  treatment  of  low  seated  strictures  of  the  trachea  and  of  stric- 
tures of  the  bronchi  is  carried  on  along  the  same  general  lines  as  those 
employed  for  the  treatment  of  strictures  higher  up,  that  is,  the  stric- 
ture is  first  dilated  and  then  held  open  by  intubation.  Such  strictures 
call  for  treatment  because  when  they  are  small  they  interfere  with 
breathing  and  expose  the  lungs  to  infection  from  the  retention  of  in- 
fected secretions.  Von  Schroetter  who  has  carried  on  extensive  investi- 
gations in  these  cases  first  dilates  the  stricture  with  a  sponge  tent  and 
then  inserts  a  metallic  tube  so  made  that  it  is  readily  retained.  It 
would  seem  that  a  mechanical  dilator  would  accomplish  the  dilatation 
more  speedily  than  the  tent. 

THE  REMOVAL  OF  FOREIGN  BODIES  FROM  THE  LARYNX, 
TRACHEA  AND  THE  BRONCHI. 

Foreign  Bodies  in  the  Larynx. 

Foreign  bodies  lodged  in  the  larynx  in  most  cases  are  either 
couched  up  after  the  initial  spasm  of  dyspnea  caused  by  them  or  drop 
into  the  trachea  or  the  bronchi.  Occasionally  the  foreign  body  is 
loosened  by  the  coughing  and  strangling  and  enters  the  esophagus  and 
is  swallowed.  Sometimes  the  foreign  body  becomes  impacted  in  the 
larynx  and  if  it  is  large  enough  it  speedily  suffocates  the  patient.  Xow 
and  then  the  foreign  body  may  be  small  enough  like  a  piece  of  egg  shell 
to  remain  in  the  larynx  or  it  may  be  of  the  right  shape  like  a  button  or 
a  coin  to  lodire  in  the  ventricles.  Fxamples  of  cases  of  both  kinds  are 
found  in  the  literature.  When  such  cases  present  themselves  direct 
examination  combined  with  the  use  of  appropriate  instruments  is  flu- 
best  method  of  removing1  the  offending  foreign  bodv. 


hAHYXliOSCOI'Y,     HKOXrilOSCOI'Y,     KS<  )l'l  I  A<  i(  )S( '( )l'\  ,     KTC. 

The  Removal  of  Foreign  Bodies  From  the  Trachea  and  the  Bronchi. 

I  ntil  the  advent  of  tracheoscopy  and  bronchoscopy  the  removal 
of  a  foreign  body  from  the  trachea  \\"as  accomplished  hy  performing 
tracheotomy.  \\Then  a  loose  body  like  a  seed  was  playing  up  and  down 
the  trachea  seeking  to  escape  it  was  often  blown  violently  out  of  the 
wound  by  the  first  spasmodic  expiration  caused  by  entering  the  tra- 
chea. Such  an  outcome  was  dramatic  and  satisfactory.  If,  however, 
the  foreign  body  was  not  free  in  the  trachea  but  was  impacted  or  was 
of  a  different  nature  from  a  seed,  the  old  practice  was  to  introduce  for- 
ceps blindly  and  to  fish  for  it.  Many  successful  extractions  have  been 
performed  in  this  manner.  Many  times,  however,  and  the  records  arc 
woefully  incomplete  as  to  how  many  times,  the  attempt  at  blind  extrac- 
tion has  failed  and  lias  caused  the  death  of  the  patient. 

It  was  a  natural  and  great  advance  in  the  treatment  of  these  cases 
when,  instead  of  the  blind  groping  after  foreign  bodies  in  the  trachea, 
the  physician  began  to  work  by  sight.  Coolidge  was  the  first  to  do  this 
in  America,  in  1S99.  By  using  a  female  uretliroscope  lie  located  and  re- 
moved a  piece  of  a  tracheotomy  tube  which  had  become  detached  and 
had  fallen  into  the  trachea.  Killian  was  the  first  to  demonstrate  the 
feasibility  of  removing  a  foreign  body  from  the  bronchus  by  means  of 
a  tube  passed  between  the  vocal  cords.  Killian  devised  and  first 
practiced  upper  bronchoscopy,  later  he  developed  lower  bronchoscopy. 
Einhorn  in  1902  devised  an  esophagoscope  having  an  auxiliary  tube  in 
the  wall  of  the  main  tube.  In  the  secondary  tube  a  light  carrier  was 
inserted  through  which  two  wires  ran  to  a  small  electric  lamp  on  the 
end  of  the  carrier.  Two  years  later  Jackson  used  the  mechanism  of 
Einhorn  on  the  Killian  tubes  and  added  a  second  auxiliary  tube  for 
drainage  purposes.  Later  the  same  investigator  lengthened  the  bron- 
choscope  and  used  it  for  exploring  the  stomach.  He  demonstrated  the 
feasibility  of  introducing  a  straight  tube  into  the  stomach  and  tauuht 
the  medical  profession  through  his  brilliant  cases  the  value  of  the  pro- 
cedure. 

The  Choice  of  the  Upper  or  the  Lower  Route. — Experience  has 
proved  that  lower  bronchoscopy  is  safer  and  easier  than  upper  bron- 
choscopy. It  is  by  all  odds  the  safer  procedure  for  the  beginner.  In 
infants  and  children  under  three  years  of  age  it  is  the 
operation  of  choice.  Even  with  older  children  up  to  the  age  of 
seven  or  eight,  if  there  is  a  loose  foreign  body  which  by  its  violent 
excursions  up  and  down  the  trachea  has  caused  trauma  to  the  lower 
part  of  the  larynx,  or  if  the  form  of  the  foreign  body  is  such  that  it  is 
impacted,  for  example,  a  bean  or  a  pin,  lower  bronchoscopy  is  surer 


204  OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 

and  safer.  If  the  operator  is  skilled,  upper  bronclioscopy  may  be  tried 
with  children  over  three  years  old.  Instances  of  success  by  this  method 
are  multiplying.  Unless  the  procedure  is  soon  successful,  however,  it 
should  be  abandoned  for  the  lower  route.  It  is  not  so  much  the  in- 
creased length  of  tubes  required  for  upper  bronclioscopy,  which  makes 
it  less  advisable  in  many  cases  than  lower  bronclioscopy — because  the 
self-lighted  tube  carries  its  light  at  the  end  and  increase  of  length  is 
not  a  serious  factor — as  it  is  the  reaction  of  the  larynx  to  the  manipu- 
lations and  the  danger  of  cardiac  arrest.  (Crile.)  This  latter  danger 
can  be  obviated  or  minimized  by  the  use  of  atropin.  Killian  has  col- 
lected nineteen  cases  in  which  after  upper  bronclioscopy  an  emergency 
tracheotomy  was  required.  The  gist  of  the  matter  seems  to  be  that  in 
the  performance  of  upper  bronclioscopy,  a  tracheotomy  may  at  any 
moment  be  called  for.  Even  after  the  successful  outcome  of  the  pro- 
cedure the  same  holds  true.  AVith  infants  and  young  children 
lower  bronchoscopy  is  preferable.  In  a  child  of  any  age  it  is  not  good 
practice  to  persist  in  upper  bronchoscopy  unless  it  is  soon  successful. 

Indications. — Tracheobronchoscopy  is  called  for  in  any  case  in 
which  the  presence  of  a  foreign  body  is  suspected.  The  dangers  of  the 
procedure  are  so  slight  that  even  when  the  presence  of  the  foreign 
body  is  not  sure  an  exploratory  bronchoscopy  is  indicated.  This  is 
especially  true  in  the  case  of  children.  The  only  contraindication  to 
bronchoscopy  is  the  presence  of  serious  organic  or  systemic  disease. 

Dangers. — The  chief  danger  in  bronchoscopy  occurs  in  the  use  of 
the  upper  route.  This  danger,  as  has  just  been  pointed  out,  arises 
from  edema  of  the  larynx  or  from  reflex  cardiac  arrest.  Tngals  has 
reported  two  cases  of  death,  one  three,  and  one  six  hours  after  the  suc- 
cessful removal  of  a  foreign  body.  These  unexplained  cases  may  have 
been  due  wholly  or  in  part  to  the  second  of  the  dangers  just  mentioned. 
Apart  from  these  two  dangers  the  most  common  one  is  septic  pneu- 
monia, from  the  trauma  occurring  during  the  manipulations  of  extrac- 
tion. Another  danger  and  one  which  can  be  easily  avoided  is  that  of 
delaying  the  performance  of  tracheotomy  when  the  patient  begins  to 
show  signs  which  call  for  it. 

The  Danger  from  Leaving  the  Foreign  Body  Alone. — The  dangers 
to  which  the  patient  is  exposed  l>y  leaving  a  foreign  body  in  place  are 
vastly  u'n-ater  than  the  danger  to  which  he  is  exposed  by  the  perform- 
ance of  bronclioscopy  at  the  hands  of  a  man  practiced  in  the  art.  The 
.UTcat  danger  incurred  by  a  patient  with  a  foreign  body  in  the  lungs  is 
pneumonia,  or  abscess  and  gangrene  of  the  lung.  In  most  instances 
either  complication  is  fatal.  There  are  many  cases  reported  in  the 
literature  of  foreign  bodies  which  have  remained  in  the  Innirs  a  lomr 


LAKYXKOSCOl'Y,    lilJONCIIosCol'Y,    KSOLM1  AGOSCOl'Y,     KTC.  L'O.") 

time  whose  presence  was  known  or  unknown,  and  which  have  been 
finally  coughed  out.  But,  judging  even  from  the  incomplete  literature 
of  the  cases  of  the  opposite  nature,  it  is  found  that  such  fortunate 
terminations  are  rare.  Should  the  patient  escape  septic  pneumonia 
and  the  foreign  body  remain  in  the  lungs,  he  is  exposed  to  tubercular 
infection  later.  Killian  is  authority  for  the  statement  that  such  cases 
not  infrequently  terminate  in  this  manner.  It  should  be  said  in  fair- 
ness, however,  that  sometimes  the  lungs  will  tolerate  a  foreign  body 
1'or  a  long  time.  The  author  has  in  mind  a  case  in  which  Coolidge  re- 
moved a  wire  nail  which  had  been  in  the  right  lung  of  the  son  of  a  phy- 
sician for  seven  years.  The  symptoms  were  only  an  occasional  cough. 
Another  case  occurs  to  the  writer.  This  patient  was  a  nurse.  For 
five  years  now  and  without  any  discomfort  she  has  had  a  metal  clasp 
pin  in  her  lung.  The  attempt  to  remove  this  pin  was  made  on  two  or 
more  occasions,  once  by  Killian  and  once  by  Jackson. 

The  degree  of  danger  which  accompanies  the  remove!  of  a  foreign 
body  naturally  varies  with  its  nature,  shape  and  size,  its  location  and 
the  condition  of  the  patient.  Rounded  objects  are  liable  to  (it  a  bron- 
chus tightly  and  to  shut  off  air  to  the  portion  of  lung  supplied  by  it. 
Therefore  they  are  most  liable  to  cause  gangrene  and  abscess.  A 
pointed  object  like  a  pin  or  a  nail  allows  air  to  pass  but  it  produces 
trauma  by  its  excursions  in  the  respiratory  blast  or  produces  erosion 
by  lying  long  in  one  position.  Either  condition  leads  to  infection. 

Inorganic  substances  macerate  and  decay.  When  this  happens 
they  may  be  coughed  out  unless  they  have  produced  a  fatal  pneumonia 
before  this  takes  place.  Seeds  if  uncooked  do  not  macerate  but  swell 
on  absorbing  moisture  and  become  firmly  fixed  in  position.  Peanuts, 
in  this  country  at  least,  have  proved  to  be  very  fatal  foreign  bodies 
to  lodge  in  the  lungs.  The  attempt  at  removal  often  crushes  them  and 
scatters  the  fragments  dee])  in  the  tertiary  bronchi. 

Roe  collected  1,417  cases  of  foreign  body  in  the  air  passages.  In 
470  extraction  was  not  attempted,  and  over  400  died,  that  is,  the  mortal- 
ity was  '27  per  cent.  This  is  to  be  compared  with  !'4  cases  of  upper  and 
lower  bronchoscopy  reported  by  Jackson  in  which  the  mortality  was 
.'!.!'  per  cent.  Tf  a  foreign  body  is  to  be  coughed  out  this  generally 
occurs  in  the  first  twenty-four  hours.  Jackson  sums  up  the  matter 
fairly  when  he  says  "we  do  full  justice  to  our  patients  when  we  tell 
them  that  while  a  foreign  body  may  be  coughed  up,  the  chances  of  this 
are  remote  and  it  is  very  dangerous  to  wait;  and  further,  the  difficulty 
of  removal  increases  with  each  hour  that  the  body  is  allowed  to  re- 
main." 

Results. — Out  of  94  cases  of  bronchoscopy  the  foreign  body  was 
removed  in  So  per  cent.  (Jackson.) 


OPERATIVE    SURGERY    OP    THE    XOSE,    THROAT,    AND    EAR. 

Symptoms.  —  Cough  is  the  most  constant  symptom  of  a  foreign 
body  in  the  air  passages.  As  the  foreign  body  passes  the  larynx  the 
cough  is  paroxysmal.  Later  at  every  attempt  of  the  air  passages  to 
expel  the  intruder  the  cough  is  again  paroxysmal.  Some  minutes  or 
hours  may  elapse  between  the  seizures.  After  a  time  the  cough  be- 
comes more  constant. 

Dyspnea  is  a  very  frequent  symptom.  It  is  usually  inspiratory 
but  it  may  occur  on  expiration.  The  dyspnea  is  worse  during  the  fits 
of  coughing  and  at  such  times  the  patient  may  become  unconscious.  It 
should  be  borne  in  mind  that  a  foreign  body  in  the  esophagus  may,  by 
pushing  forward  the  soft  trachea  of  a  child,  produce  dyspnea. 

The  temperature  is  usually  elevated.  This  might  be  taken  as  evi- 
dence in  the  doubtful  cases  against  the  presence  of  a  foreign  body.  In 
late  cases  in  which  pneumonia  has  set  in  naturally  the  temperature  is 
elevated. 

Chills  occur  when  an  abscess  has  been  produced  about  the  foreign 
body. 

Hemoptysis  is  not  present  as  a  rule.  It  is  associated  with  the  aspi- 
ration of  sharp  substances. 

Pain  is  often  present  but  it  is  generally  poorly  localized. 

Diagnosis.  —  The  fluoroscope  is  not  reliable  in  locating  a 
foreign  body  unless  it  is  very  dense.  An  X-ray  plate  should  be  taken 
in  all  cases  and  interpreted  by  an  expert.  The  physician  who  is  not  ac- 
customed to  reading  plates  taken  of  the  lungs  is  very  liable  to  mistake 
spots  of  calcification  along  the  main  branches  of  the  bronchi  for  for- 
eign bodies.  Unless  there  is  marked  dyspnea  it  should  be  the  routine 
to  obtain  a  radiograph. 

Metallic  substances  with  the  exception  of  aluminum  show  well  in 
the  plate.  So  do  pebbles  and  objects  of  glass.  Bones  unless  they  come 
in  front  of  another  bone  like  a  vertebra  also  show  well.  Fish  bones 
come  out  poorly  in  the  plate.  Vegetable  substances  with  the  exception 
of  some  kinds  of  wood,  do  not  cast  much  of  a  shadow.  The  same  is  true 
of  peanuts  and  chestnuts  without  their  shells.  It  is  difficult  to  obtain 
a  satisfactory  X-ray  of  a  young  child  unless  it  is  etherized.  Only  in 
the  case  of  a  metallic  foreign  body  when  the  plate  shows  nothing  is  it 
safe  to  pei-mit.  the  patient  to  go  without  an  examination.  Intermittent 
contrh  and  dyspnea  not  to  be  explained  in  any  other  way  and  not  asso- 
ciated willi  fever  is  almost  diagnostic  of  the  presence  of  a  foreign  body. 

The  Physical  Signs.     The  physical  signs  arc  of  value  in  deterinin 
ing  1  he  presence  of  a  foreign  body  in  1  lie  ai  r  passages  i  f  1  hey  a  re  elicit  ed 
and   interpreted   by  a   physician   who  possesses    a    good    and    sufficient 
hnic  in  auscultation  and   percussion.    The  phvsical   signs  are  relied 


ec 


LARYXOOSCOl'Y,     I5IJO  X( '  1 1  OSCOl' Y,     KS( )]'!  I  A<  iOS( '( >\'\  ,     K'I'C.  _( 1 1 

upon  most  in  those  cases  in  which  a  positive  X-ray  cannot  lie  secured. 
The  following  paragraphs  which  hear  upon  the  physical  siu'iis  and  their 
moaning  are  ahstractcd  from  Jackson  for  whom  they  were  written  hy 
Boyce. 

In  the  examination  a  distinction  must  he  made  hetwecn  the  signs 
due  to  the  foreign  hody  and  those  which  are  due  to  inflammatory  con- 
ditions which  soon  supervene. 

A  foreign  hody  which  is  obstructing  a  bronchus  may  lead  to  atelcc- 
tasis  of  the  lung.  If  so,  the  usual  signs  are  present.  This  occurrence, 
however,  is  not  as  frequent  as  is  generally  supposed.  The  most  com- 
mon finding  is  a  marked  local  diminution  of  the  respiratory  murmur 
with  preservation  or  accentuation  of  the  normal  resonance.  This  may 
be  called  the  typical  condition.  When  a  foreign  body  partially  ob- 
structs a  bronchus  it  may  give  rise  to  a  peculiar  dry  rale  which  is  easily 
differentiated  from  that  given  by  inflammatory  or  tubercular  thicken- 
ings of  the  mucous  membrane.  These  dry  rales  are  limited  to  a  defi- 
nite area  and  occur  for  hours  at  a  time. 

Bronchitis  is  the  commonest  inflammatory  condition  following  the 
inhalation  of  a  foreign  body.  The  secretions  from  this  are  soon  dif- 
fused through  the  lungs  and  give  the  signs  of  a  diffuse  bronchitis. 
Diffuse  bronchitis  coming  on  suddenly  and  especially  if  it  is  accompa- 
nied by  bloody  expectoration  is  a  most  unusual  condition  and  should 
raise  the  suspicion  of  the  presence  of  a  foreign  body.  The  expectora- 
tion in  foreign  body  cases  is  usually  bloody  and  tends  to  become  abun- 
dant, purulent  and  fetid.  In  such  instances  only  the  history  and  a  care- 
ful examination  of  the  sputum  will  rule  out  tuberculosis.  If  a  localized 
abscess  is  present  or  lobar  pneumonia,  the  signs  of  these  conditions  are 
the  same  as  when  they  are  not  associated  with  a  foreign  body.  In  one 
case  plural  effusion  resulted  from  the  presence  of  a  foreign  body  and 
the  patient  was  twice  tapped.  (Ingals.) 

Tuberculosis  "without  bacilli  in  the  sputum"  particularly  if  the 
disease  is  located  near  the  base  of  the  right  lung,  unilateral  or  unilob- 
ular  bronchitis  and  especially  if  liemorrhagic  or  fetid,  atelectasis,  ab- 
scess or  gangrene,  not  otherwise  explainable,  should  raise  the  sus- 
picion of  the  presence  of  a  foreign  body  in  the  air  passages. 

The  Location  of  foreign  bodies  varies  with  the  size  and  shape 
of  the  objects.  Bodies  of  some  size  usually  lodge  at  the  bifurcation  of 
the  trachea  or  enter  the  right  main  bronchus.  Pins  often  lodge  at  the 
bifurcation,  one  half  the  pin  being  in  the  trachea  and  the  other  half 
lying  in  a  primary  bronchus.  (Fig.  Io4. )  Pins  and  nails,  however,  not 
infrequently  fall  into  the  smaller  bronchi.  In  the  experience  of  the 
author  pins  and  nails  frequently  lodge  in  the  inner  branch  of  the 


1'OS 


ol'KKATIVE    SURGERY    OF    THE    XOSE.    THROAT,    AND    EAR. 


bronchus  to  the  inferior  lobe  of  the  rig'lit  luiiii1.    Safety  ]»ins  if  they  are 
open  do  not  ,u'et  beyond  the  trachea. 

The  Technic  of  Removing  Foreign  Bodies. — The  first  tiling  to 
accomplish  is  to  brinii1  the  foreign  body  into  view.  The  manipulations 
of  the  bronchoscope  which  are  necessary  to  accomplish  this  have  been 
described.  After  locating  the  foreign  body  and  obtaining  a  ii'ood  view 
the  next  important  step  is  to  use  the  proper  instrument  for  seizing  it. 
Many  a  case  has  resulted  in  disappointment  owin.u'  to  the  fact  that  the 
physician  went  ahead  without  suitable  instruments.  I'nless  the  case  is 


FiR.   154. 
Pin    with   glass  head   in   left    main   bronchus. 

desperate  time  should  be  taken  to  procure  a  forceps  with  a  tip  fitted  to 
irrasp  the  particular  object  dealt  with.  l>eans  and  seeds  call  for  a 
special  tip.  Pins  may  be  extracted  with  the  ordinary  forceps,  but  in 
case  the  pili  is  impacted  the  pin  cutter  of  Casselberry  (  Kit;1.  l.V>)  is 
essential.  The  usual  bronchoscope  has  lateral  openings  in  the  lower 
third  or  half  of  its  length  so  that  air  may  not  be  shut  off  from  the 
opposite  limu'  diinnir  the  examination.  \Vhcn  dealing  with  a  pin  these 
opeiinm'>  should  not  come  to  the  end  of  the  tube,  otherwise  the  pin 
may  be  canu'lit  in  them.  Open  safety  pins  are  best  extracted  with  a 
clox-r  I  I) ninnies,  Mosher,  or  llubbard). 


LARYNUOSCOPY,    BRONCHOSCOPY,     KSOI'II  AOOSCOI'Y,     KTC. 


Soft  pliable  substances  like  rubber  call  for  a  corkscrew-like  instru- 
ment as  in  the  case  reported  by  Richardson. 

The  greatest  difficulty  is  found  in  the  extraction  of  small  bodies 
deeply  placed  in  the  bronchi.  These  are  often  macerated  or  imbedded 
in  swollen  mucosa.  In  working  in  the  smaller  bronchi  and  near  the 
periphery  of  the  lung  the  physician  may  find  it  necessary  on  account 
of  poor  light  or  the  diminutive  field  to  pass  the  forceps  beyond  the  tube 
and  to  close  them  blindly.  Before  this  maneuver  is  executed  a  mark  is 
placed  on  the  shaft  of  the  forceps  to  show  the  length  of  the  tube. 

Hooks  of  various  shapes  are  useful  to  pass  beyond  a  foreign  body 
in  order  to  prevent  the  forceps  from  pushing  it  down  or  to  turn  the  for- 
eign body  so  that  the  blades  of  the  forceps  can  grasp  it.  The  hook  is 
passed  flat  until  beyond  the  object  and  then  turned  and  brought  up. 


-    2 


Fig.  155. 
Casselberry's   pin   cutter 


Care  is  required  not  to  catch  the  end  of  a  fully  curved  hook  in  the  open- 
ing of  a  bronchus. 

In  the  case  of  hollow  foreign  bodies  expanding  forceps  are  of 
service.  If  the  foreign  body  is  lodged  in  a  small  cavity  of  the  lung  it 
may  be  necessary  to  dilate  the  opening  into  the  cavity  before  the  for- 
eign body  will  come  into  view  and  permit  extraction.  .Jackson  has  de- 
vised a  dilator  for  this  purpose. 

Usually  secretion  is  seen  coming  out  of  the  bronchus  in  which  the 
foreign  body  is  lodged.  Inflammatory  swelling  may  indicate  that  the 
bronchus  is  invaded.  A  probe  may  be  required  to  locate  the  foreign 
body.  A  suction  apparatus  is  useful  for  removing  fragments  of  seeds. 

The  After-Effects  of  the  Removal  of  Foreign  Bodies. — I'M  less 
edema  of  the  larynx  follows  the  manipulations  required  for  the  re- 
moval of  a  foreign  body  the  after-effects  of  bronehoscopy  are  slight. 
There  may  be  some  hoarseness  for  few  days  or  a  slight  localized  bron- 
chitis. This  is  trivial  and  soon  disappears. 


OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 

ESOPHAGOSCOPY. 

History. — Soon  after  the  invention  of  the  laryngoscope  attempts 
were  made  to  see  the  opening  of  the  esophagus  by  pulling  the  cricoid 
cartilage  forward  with  appropriate  specula  and  then  obtaining  a  view 
by  means  of  a  mirror  held  above  in  the  pharynx.  These  experiments 
led  to  no  practical  results.  In  18(58  Bevan  by  means  of  a  thin  speculum, 
and  two  years  later  Waldenburg  by  means  of  a  tubular  speculum 
14  cm.  long  succeeded  in  seeing  the  mouth  of  the  esophagus.  The  latter 
also  made  an  ocular  diagnosis  of  a  diverticulum. 

Stork  was  the  first  man  to  pass  a  solid  tube  into  the  esophagus  and 
to  carry  out  direct  esophagoscopy.  Kussmaul  (18(58)  explored  the 
esophagus  with  a  rigid  tube  and  published  his  observations  on  the  nor- 
mal and  the  diseased  esophagus,  while  his  pupil  Miiller  established  the 
important  clinical  fact  that  the  normal  esophagus  should  admit  a  tube 
I']  nun.  in  diameter.  The  observations  of  Kussmaul,  however,  made 
little  headway;  later  they  were  revived  and  popularized  by  Killian. 

Stork  and  Kussmaul,  then,  were  the  two  men  who  gave  esophago- 
scopy its  start.  V.  ^Mikulicz,  a  follower  of  Stork,  was  the  next  worker 
whose  results  proved  to  be  fundamental.  By  the  year  1881  he  had  car- 
ried out  most  important  anatomic  and  physiologic  researches  and  had 
noted  common  pathologic  changes.  For  the  next  ten  years  no  special 
advances  in  esophagoscopy  were  made.  Since  that  time  this  method  of 
investigation  has  been  pursued  with  vigor.  The  advances  have  been 
along  the  line  of  improved  teclmic  and  new  instruments. 

Anatomy. — The  esophagus  is  a  muscular  tube  which  is  the  con- 
tinuation of  the  pharynx.  It  starts  from  the  back  of  the  cricoid  carti- 
lage opposite  the  sixth  cervical  vertebra.  At  the  mouth  of  the  esopha- 
gus the  lower  border  of  the  inferior  constrictor  muscle  projects  like  ;', 
mound  into  its  lumen  and  acts  as  a  sphincter  in  a  way  similar  to  th;1 
action  of  the  superior  constrictor  (Passavant's  fold)  in  the  upper  part 
of  the  pharynx. 

Structure.— The  esophagus  has  an  outer  muscular  coat  of  two 
layers  and  an  inner  glandular  coat  covered  with  pavement  epithelium. 
A  connective  tissue  layer  joins  the  two  chief  layers.  The  thickness  of 
the  esophagus  is  .'!  to  4  mm.  'Die  outer  layer  of  the  muscular  part  con- 
sists of  longitudinal  fibers  and  the  inner  layer  of  circular  ones.  (Fig. 
1  of).)  The  anterior  longitudinal  fibers  arc  attached  to  the  back  of  the 
cricoid  cartilage.  The  inner  layer  of  circular  muscular  fibers  is  a  con- 
tinuation downward  of  the  fibers  of  the  inferior  constrictor  muscle. 
Tin-  upper  end  of  the  esophagus  therefore  is  the  lower  end  of  the 
pharynx,  so  that  voluntary  muscular  fibers  predominate.  From  this 


LAUYNOOSCOI'Y,     UUONC  1 1  OSCOI'Y  ,     KS(  )|'  1 1  A< ',( )S( '( >!">  ,     KTC. 


I'll 


it  happens  that  a  foreign  body  arrested  at  the  entrance  of  the  esopha- 
gus is  often  thrown  back  into  the  pharynx  and  into  the  mouth. 

Lymphatics. — The  lymphatics  of  the  esophagus  enter  both  the 
mediastinal  and  the  cervical  glands  so  that  in  suspected  cancer  of  th" 
esophagus  the  glands  at  the  root  of  the  neck  should  be  examined. 

Position. — The  esophagus  has  the  vertebral  column  behind  it  and 
the  trachea  in  front,  and  lies  in  the  posterior  mediastinum.  At  the 
fourth  thoracic  vertebra  the  arch 
of  the  aorta  makes  a  transverse  con- 
striction in  it  and  a  vertebra  lower 
down,  the  left  main  bronchus,  at  the 
fifth  thoracic,  makes  an  oblique  line 
across  its  front  surface.  Below  this 
point  the  heart  lies  on  it  like  a 
weight.  In  the  lower  part,  the  right 
and  left  piieuniogastric  nerves  lie  on 
the  sides  of  the  esophagus,  and  back 
of  the  arch  of  the  aorta  the  thoracic 
duct  crosses  from  right  to  left  lie- 
bind  it,  on  the  front  of  the  vertebral 
column.  (Fig.  157.) 

Direction.  --  The  esophagus  is 
placed  for  the  most  part  a  little  to 
the  left  of  the  middle  line.  Midway 
in  its  course,  at  the  fourth  thoracic 
vertebra,  it  swings  to  the  central 
line,  back  of  the  arch  of  the  aorta, 
but  at  once  goes  to  the  left  again 
and  enters  the  stomach  to  the  left 
and  in  front,  of  the  aorta,  at  the 
eleventh  thoracic  vertebra.  This 
deviation  from  the  center  does  not 


-sSggiasp^ 

Fig.   156. 

Section  of  the  human  esophagus  (.Mod- 
erately magnified).  The  section  is  trans- 
verse, and  from  near  the  middle  of  the 
gullet.  (Quain's  Anatomy — From  a  draw- 
ing by  V.  Horsley.) 


a.  fibrous  covering;    b.  divided   fibres  of 
the  longitudinal   muscular  coat;    c.   trans- 

vers?  mVseular  "bres:    '/'   Sllbnuieous  »r 
areolar   layer;    c.   musculans   mucosse:    /. 

interfere    with    the    passing    of   1)011-       mucous  membrane,  with  vessels  and  part 

of  a  lymphoid  nodule;     </.    laminated  epi- 
gies    or    tubes   except    at     the     lower      thelial  lining;    J,.  mucous  gland;    i.  gland 

part  where  the  esophagus    pierces     dm't:   m-  striated    muscular    til)r''s    ('nr 

across. 

the  diaphragm.  (Figs.  1.5S  and  1  .">}).) 

The  Diameter. — Only  in  the  region  of  the  month  of  the  esophagi^ 
is  the  diameter  relatively  fixed.  The  esophagus  is  constricted  at  four 
points.  Of  these  the  upper  and  the  lower  ones  are  the  most  important. 
The  upper  one  is  caused  by  the  projection  backward  of  the  cricoid  carti- 
lage, the  lower  by  the  encircling  fibres  of  the  diaphragm.  The  up- 


212 


OPERATIVE    SUKCEHV    OF    THE    NOSE,    THROAT,    AND    EAR. 


per  one  hinders  the  introduction  of  the  examining  tube,  the 
lower  one  obstructs  the  passage  of  the  esophagoseope  into  the 
stomach.  The  first  constriction  is  a  transverse  slit,  slightly  less  than 
an  inch  wide;  the  second  constriction  is  about  of  the  same  width.  The 
loiiii1  axis  of  this  constriction  is  from  right  to  left  from  behind  forward. 


Right  common  carotid  artery 
A    carotis  communis  dcMra 
Internal  jugular  vein 
V.  juRulnris  internrx 
Pneumogastric  nerve 
N.  vagus 

Inferior  thyroid  artery 
A.  thyreoidea  inferior 


Laryngeal  part  of  the  pharynx 
I'ars  larynsea 

Thyroid  body 

Clan  !ui:i  tlivre'jidp.1 


tlic    rdalions    of   llic   csoplia^'iis    from    hdiiinl.      (From    Toldt.i 


The  liinien  of  Ihe  esojihagus  al  Ihis  point  is  subject  to  wide  variatii 
\\'liicli  depend  upon  the  relaxation  or  the  contraction  of  the  diaphragm. 
In  addition  to  these  two  important  constrictions  there  are  two  others. 
Often  they  are  not  seen  unless  closely  watched  for,  and  they  disappear 


LARYNOOSrOl'Y.     I5KOXC  IIOSCOI'Y,     KSOIMIAOOSCOI'Y,     KTC. 


completely  if  large  tubes  arc  used.  The  first  of  these  minor  constric- 
tions corresponds  to  the  arch  of  the  aorta,  and  is  found  at  the  level  of 
the  junction  of  the  first  and  second  pieces  of  the  sternum  and  in  front 


Fig.  158. 

View  of  the  stomach  in  situ  after  removal  of  the  liver  and  the  intestine 
(except  the  duodenum  and  commencement  of  jejunum).  (Quain,  after 
Testut.) 

A,  diaphragm;  B,  B',  thoracico-abdominal  parietes:  C,  right  kidney  with 
<•.  its  ureter;  D.  right  suprarenal  capsule:  E,  left  kidney  with  c.  its  ureter; 
F,  spleen;  G,  G',  aponeuroses  of  the  transverse  abdominal  muscles;  H.  right 
quadratus  lumborum  muscle;  11',  left  ditto;  I,  right  psoas  magnus  and 
parvus  muscles;  I',  left  ditto;  K,  esophagus:  L,  stomach:  M.  duodenum: 
N,  jejunum;  the  position  of  the  duodeno-jejunal  junction  behind  the  stomach 
is  indicated  by  dotted  lines.  1.  termination  of  oesophagus:  2.  great  curv- 
ature of  stomach;  3,  small  curvature:  4.  fundus:  5.  ant  rum  pylori:  t5,  pyloric 
end:  7,  right  vagus  nerve:  8.  left  ditto:  !>.  thoracic  aorta:  !»'.  abdominal 
aorta;  10,  inferior  phrenic  artery;  11,  coeliac  axis;  12,  hepatic  artery:  1:',, 
right  gastro-epiploic:  14,  coronary  artery:  15.  splenic  artery;  16,  1*5'.  superior 
mesenteric  artery  and  vein;  17.  inferior  mesenteric  artery:  IS.  spermatic 
arteries;  1!»,  gall  bladder:  20,  cystic  duct:  21.  hepatic  duct:  22,  inferior 
vena  cava:  23,  portal  vein;  24.  sympathetic  cord. 

of  the  fourth  thoracic  vertebra.     The   last  constriction,   which    is  the 
third  from  above  downward,  is  made  bv  the  crossing'  of  the  left   bron- 


214 


OPERATIVE    STRCERV    OF    THK    XOSE.    THROAT,    AND    EAR. 


elms  in  front  of  the  esophagus.  It  occurs  at  the  level  of  the  fifth  tho- 
racic vertebra. 

The  Length  of  the  Esophagus. —  In  men  the  distance  from  the  in- 
cisor teetli  to  the  beginning  of  the  esophagus  is  15  cm.  and  in  women 
14  cm.  The  distance  from  the  incisor  teeth  to  the  bifurcation  of  the 
aorta  is  26  cm.  in  men,  and  1*4  cm.  in  women.  In  men  the  length  of  the 
esophagus  from  the  incisor  teeth  varies  between  .'>(>  cm.  and  f)9  cm.,  the 
normal  average  distance  being  40  cm.  In  women  the  figures  are  a  little 
smaller,  '.I-  to  41,  the  average  being  .'58  cm.  \Vhen  flexible  bougies  are 
used  for  measuring  1  to  .'>  cm.  should  be  added  to  these  measurements. 

Distensibility. — All  the  constrictions  of  the  esophagus  are  dis- 
tensible. The  upper  constriction  is  less  dilatable  than  the  others,  so 
that  this  is  the  one  which  gives  the  greatest  trouble  in  esophagoseopy. 

The  normal  esophageal  wall  according  to  Jackson  will  stretch  2 
cm.  without  rupture.  At  times  foreign  bodies  stretch  it  more  than  this. 


Fig.  lf.it. 

lTn<lcr  surface  of  the  diaphragm.    E,  Hiatus  esophagus.    Xote  the  direc- 
tion  of  its  axis.      (After  Jackson.) 

In  infants  a  tube  of  7  mm.  should  pass  readily  and  in  the  adult  a 
tube  which  has  a  diameter  of  14  mm.  In  infants  a  flexible  bougie  S  nun. 
should  pass  and  in  adults  one  that  measures  14  mm. 

With  light  stretching  the  transverse  diameter  of  the  esophagus  is 
L'.'!  mm.  at  the  erieoid  cartilage  and  17  mm.  anteroposteriorly.  The 
diameter  of  the  esophagus  as  it  goes  through  the  diaphragm  is  24  to 
2-")  mm.  Two  stomach  tubes  can  be  passed  side  by  side.  Briinings  states 
that  the  esophagus  at  its  mouth  can  be  dilated  to  .">(>  mm.  without  dan 
ger. 

At  the  lower  end  of  the  esophagus  V.  Mikulic/.  in  his  operation  for 
cardiospasm  stretched  the  lumen  to  7  cm.  so  that  the  hiatus  had  a  cir- 
cumference of  1  (i  cm. 


LAHYNOOSCOl'V,     HROXCHOSCOI'Y,     KSOI'  1 1  A<  i(  )S( '< 


. )   wide. 

inch   it 

<•  direc- 


The  distensibility  of  the  esophagus  is  much  greater  in  the  livini1 
than  in  the  dead.  On  the  dead,  when  the  esophagus  is  stretched  trans- 
versely only,  it  dilates  to  40  mm.,  or  one  and  one-half  inches.  The  or- 
dinary full-sized  tooth  plate  is  two  and  one-quarter  inches  (f>7 
broad.  A  fifty-cent  piece  is  one  and  one-eighth  inches  (.'10 
Since  the  transverse  diameter  of  the  esophagus  is  about 
would  seem  as  if  this  coin  should  pass  readily  in  an  a< 
tion  in  which  the  esophagus  will  stretch 
the  most  is  from  side  to  side.  For  this 
reason  oval  tubes  take  up  the  slack  in 
the  esophagus  along  anatomic  lines  bet- 
ter than  round  ones. 

The  Subphrenic  Portion  of  the  Esoph- 
agus.—  Beginning  at  the  level  of  the 
bifurcation  of  the  trachea  the  esophagus 
comes  to  the  front  and  passes  over  the 
descending  aorta  and  enters  the  abdo- 
men through  the  hiatus  or  the  opening 
in  the  diaphragm.  This  subphrenic  part 
of  the  esophagus  varies  much  in  shape 
according  as  the  stomach  is  empty  or 
distended.  In  persons  of  spare  build  it 
has  a  lateral  range  of  movement  amount- 
ing to  10  or  If)  cm.  (Fig.  100.) 

The  Movements  of  the  Esophagus.— 
The  esophagus  is  never  twice  alike  even 
in  the  same  individual.  At  the  level  of 
the  fourth  thoracic  vertebra  (-4  cm. 
from  the  teeth)  the  throbbing  of  the 
arch  of  the  aorta  can  be  seen  if  watched 
for  and  a  little  lower  at  the  level  of  the 
seventh  and  eighth  thoracic  vertebra  CIO  Schema  showing  the  range  of 

motion    of    the    gastroscope    at    the 

cm.  from  the  incisor  teeth).     The  back-     mouth  of  the  esophagus  and  at  the 

T  T  s    ,  .,          hiatus    of   the     diaphragm.      (After 

ward  mounding  or   the    heart    and    its     ja(.kson.» 
beating  are  visible. 

If  a  relatively  small  esophagoscope  is  used  for  the  examination  the 
esophagus  opens  with  inspiration  and  partially  closes  with  expiration. 
These  changes  occur  chiefly  in  the  thoracic  portion,  and  are  due  to  the 
negative  intrathoracic  pressure.  If  a  large  tube  is  used  the  esophagus 
stands  wide  open  after  the  cricoid  cartilage  has  been  passed  and  the 
respiratory  changes  nearly  disappear. 

During  swallowing  peristaltic  movements  pass  along  the  esopha- 


216 


OPERATIVE  SUROKKY  OF  THE  XOSE,  THROAT.  AND  EAK. 


gus  from  above  downwards,  while  in  vomiting  the  movements  arc  re- 
versed. 

There  is  good  evidence  to  support  the  assertion  that  there  is  a 
sphincter  at  the  cardiac  end  of  the  esophagus,  due  to  the  presence  of 
two  layers  of  muscular  fibers  as  described  by  Hyrtl.  According  to 
Jackson,  the  presence  of  this  sphincter  is  not  the  chief  agency  through 
which  the  regurgitation  of  food  is  prevented.  This  observer  maintains 
that  the  kinking  of  the  esophagus  below  the  opening  of  the  diaphragm 
and  the  increase  of  this  twist  by  distension  of  the  stomach  has  much 
more  to  do  with  keeping  the  food  in  the  stomach  than  the  presence  of 
the  cardiac  sphincter.  From  a  few  anatomic  findings  which  have  come 
to  the  notice  of  the  author  lie  is  inclined  to  think  that  Jackson's  posi- 
tion will  be  sustained. 

Measurements  of  the  Esophagus. — The  following  tables  are  com- 
piled from  Stark.  They  are  of  use  for  reference. 


DlAMKTKUS    OF     I  1 1  K    Ksoi'l !  ACiTS     AT     I  1 1  K    Foil!    Co  X  STKK  TIO  .\  S. 

Constriction.  Diameter. 


Cricoid Transverse  2?>  mm.   (1  in.)    

Anteroposterior  17  mm.  (:;,  in.) 
Aortic Transverse  24  mm.  (1  in.)  

Anteroposterior  l!t  mm.  (:!t  in.) 
Left  bronchus Transverse  2:5  mm.  ( 1  in. )  

Anteroposterior  IT  mm.  (  ::i  in.) 
Diaphragm  Transverse  2'.]  mm.  (1  in.  +)  ., 

Anteroposterior  '!'•',  mm.    (  1   in.  — 


Vertebra. 
Sixth  cervical. 
Fourth  thoracic. 
Fifth   thoracic. 
Tenth  thoracic. 


I.KM.TII     01      Till:     ESOI'II  ACTS     AT     Dll'IKKKXT     A(,KS. 


Teeth  to  Cricoid. 


To 

Bifurcation. 


To  Cardia. 


Mirth 

1    ye 

'1    ye 

fi    ye 

lo  ye 

If,    ye 

Adult 


7   cm.  (2::,  in. ) 12  cm.  (  4: 

ir.     10  cm.  (4  in. ) 14  cm.  (  f>  t 

irs,   lo  cm.  (4  in. ) 1~>  cm.  (  *> 

irs.    lo  cm.  (4  in. ) 17  cm.  (  (>•' 

irs,   10  cm.  (4  in. ) 18  cm.  (  7 

irs,   14   cm.  (">'._,  in.) 2:!  cm.  (  !» 

in  cm.  ( fi  in.  i  .  .        .  2t; 


in. )   18  cm.  (   »>•"•,  in.  ) 

in.  i   22  cm.  (    8",  in   i 

in.  i   2:!  cm.  (ft  in. ) 

in. )   2(i  cm.  (ID1  ',  in.  i 

in   i    28  cm.  (11  in. ) 

in. )   )!:!  cm.  ( II!  in.  ) 


(  lo  '  i    in. )   40   cm.    (  l.r:,    in.  i    2 


For  memorizing  the  length  of  the  esophagus  at  different  ages  the 
following  approximate  figures  are  given:  IVirth,  7  inches;  .">  years,  10 
incho;  1 .")  years,  1.'!  inches;  '!')  years  or  adult,  l(i  inches  Add  three 
inches  for  every  five  years.  (Stark.) 

I  M  \  \i  I.I  i-.i:  01    Ti  i:i-.s   i-oi;    DiHi.u.vr   AI.KS. 

To  S  yi  ars   '.i   mm. 

l-'rom  !•  to   1  ."i  years   11    mm. 

From    17   years    12  to    11    mm. 

Adults     .  11    m  m.  (  average. ) 


LAKYNOOSCOl'Y,     BK<  ).\( '  1 1  <  >S< '<  >]'Y  ,     KSOIMTAOOSCOI'V,     KTC.  _]/ 

The  esophagus  begins  (5  inches  from  the  ineisor  leelli,  hack  of  the 
cricoid  carl  ilage  at  the  sixth  cervical  vertebra.  It  is  ID  inches  long,  and 
goes  through  the  diaphragm  at  the  tenth  thoracic  vertebra,  Hi  inches 
from  the  teeth.  It  is  crossed  by  the  arch  of  the  aorta  back  of  the  middle 
of  the  first  piece  of  the  sternum,  10  inches  from  the  teeth.  The  measure- 
ments to  be  remembered  in  connection  with  it  are,  then,  (i  and  10. 

Contraindications  to  Esophagoscopy.- -The  only  contraindications 
to  the  performance  of  esophagoscopy  are  acute  inflammation  as  after 
the  swallowing  of  corrosive  fluids,  and  aneurism  of  the  aorta.  Th  • 
chief  danger  in  the  passage  of  the  esophagoscope  is  rupture  of  the  eso- 
phagus. This  almost  always  results  in  infection  of  the  posterior  medi- 
astinum and  death.  Such  an  accident  should  be  easily  avoided  by  tin- 
selection  of  a  tube  of  the  proper  si/e  and  by  adhering  always  to  the  fun- 
damental axiom  of  all  esophageal  examinations,  namely,  the  examin- 
ing tube  must  never  be  advanced  unless  the  eye  of  the  physician  sees 
the  open  esophagus  ahead  through  the  tube.  It  is  well,  also,  to  remem- 
ber that  in  old  people  the  esophageal  wall  may  be  thin  enough  to  rup- 
ture of  itself  so  that  in  the  elderly  smaller  tubes  and  greater  care  in 
using  them  are  necessary.  It  has  developed  of  late  years  that  there  is 
considerable  shock  from  manipulations  carried  out  in  the  esophagus. 
Indeed,  working  in  the  esophagus  causes  more  shock  than  working  in 
the  trachea  and  bronchi.  Relatively  children  do  not  bear  esophageal 
examinations  as  well  as  adults.  When  a  patient  is  poorly  nourished, 
and  especially  if  he  is  on  the  point  of  starvation  from  the  presence  of 
a  stricture,  it  is  better  practice  to  open  the  stomach  and  feed  the  patient 
through  a  gastric  fistula  until  his  resistance  lias  been  restored  before 
attempting  any  prolonged  esophageal  examination. 

Anesthesia. — The  esophagus  may  be  examined  under  local  or  gen- 
eral anesthesia.  In  Kuropean  clinics  local  anesthesia  is  employed  for 
adults  almost  exclusively.  Children  are  examined  under  ether  or 
chloroform.  In  this  country  many  examinations  are  carried  out  under 
U'eneral  anesthesia.  The  author  is  very  much  prejudiced  in  favor  of  ;, 
general  anesthetic.  If  the  manipulations  under  cocain  anesthesia  are 
successful  the  operator  gains  his  point,  but  if  the  examination  is  nega- 
tive no  conclusions  can  be  drawn  from  it  and  the  case  remains  in  doubt. 
On  the  other  hand,  if  the  examination  lias  been  conducted  under  ether 
and  the  result  is  negative  both  the  patient  and  the  physician  feel  confi- 
dence in  the  finding.  1'nder  ether  larger  tubes  can  be  used  which 
means  a  better  view  and  a  larger  field  for  the  manipulation-.  In  addi- 
tion under  such  conditions  the  treatment  called  for  by  the  case,  for 
example  the  dilatation  of  a  stricture,  can  be  made  more  efficient. 

Instruments. —  In  esophagoscopy  all  bridges  must  be  crossed  before 


-18  OPERATIVE    SUROERY    OF    THE    NOSE,   THROAT,    AND    EAR. 

the  operator  gets  to  them.  In  other  words  the  physician  must  be  will- 
ing to  supply  himself  at  the  beginning  of  his  work  in  this  line  with  a 
full  set  of  general  and  special  instruments.  As  everything  depends 
upon  light  it  is  good  economy  to  have  two  sets  of  tubes,  one  set  being 
the  self-lighted  tubes  of  Einliorn- Jackson,  and  the  other  the  extension 
tube  of  Briinings  which  is  lighted  by  having  the  light  projected  through 
it  from  the  electroscope.  (Fig.  161.) 


Fig.     161. 
Jackson's  esophagoscope.     The  drainage  tube  runs  the   whole  length   of  the  instrument. 

The  list  recommended  is  as  follows: 

1.  One     7  mm.  Jackson  tube. 

2.  One  14  mm.  Jackson  tube. 

3.  One  adult  tubular  speculum    (Jackson). 

4.  One   tubular  speculum,   children's  size    (Jackson):    or   one   adjustable   speculum 

(Mosher). 

5.  One   Hrunings'  or  Kahler's  electroscope. 

6.  One  Briinings'  extension  esophagoscope,  about  7  mm. 

7.  One  Briinings'  extension  esophagoscope,  14  mm. 

8.  Xine  Coolidge's  cotton  carriers.     Three  25,  throe  35,  and  three  50  cm.  long. 

9.  One  grasping   forceps  with   three  shafts — 25,  35,  and    50  cm.    long    respectively 

(Coolidge  or  Jackson);  or  one  extension  forceps  (Briinings)  with  three  tips — 
claw  toothed  tip,  tip  for  grasping  seeds,  and  a  punch  tip. 

10.  One  esopliageal    dilator    (Briinings,    Mosher). 

11.  One  metal   probe  carrying  three  graduated   olives    (Bunt    pattern). 

12.  One  set  elastic  esophageal   bougies   from   the  smallest    si/.e   to   No.   4o    (French). 

The  series  should   be  complete  up  to  No.  20. 

13.  One  Casselberry's  pin  cutter. 

14.  One  Jackson's  safety  pin   forceps;    or  one  Mosher's  safety   pin  closing  tube. 

15.  One  tooth  plate  cutter   (Kahler  or  Mosher). 

16.  One  metal  staff  having  a  perforated  olive  at  the  tip.     A  set   of  graduated  oli\vs 

and  a  flexible  introducer    (Mixter  and  Mosher). 

17.  One   suction    apparatus.     Kit  her   a    hand    bulb,   Jackson's   secretion   aspirator,   or 

a    suction    apparatus    run    by    electricity.     When    needed    this    last    apparatus 
is  a   great    luxury. 

The  author  does  most  of  his  esopliageal  work  under  ether  and  pre- 
fers to  use  as  large  a  tube  as  the  esophagus  under  examination  will 
take.  Accordingly  lie  uses  a  large  oval  tithe  of  two  lengths.  (Kig.  Hill.) 


LARYXGOSCOPY,     BRONCHOSCOPY,     KSOI'H.M  ;osro|'Y,     KTC. 

The  tube  has  a  mandarin  which  projects  from  the  end  an  inch  and  a 
half.  The  pointed  end  of  the  plunger  readily  finds  the  opening  of  the 
esophagus  and  pushes  the  cricoid  cartilage  forward  and  allows  the 
tube  to  slip  by.  The  tube  has  no  secondary  tube  on  the  outside  either 
for  the  light  or  for  suction.  The  tube  is  therefore  smooth. 
The  introduction  of  the  large  tubes  with  secondary  tubes  on  the 
side  is  dangerous  because  the  tubes  tend  to  cut.  The  author  had  one 
fatality  due  to  this  cause.  Instead  of  the  suction  tube  a  short  tube 
conies  off  from  the  main  tube  near  its  upper  end.  This  is  for  the  intro- 
duction of  air.  The  tube  is  fitted  with  a  metal  plug  which  has  a  glass 
end.  "When  this  window  plug  is  in  place  the  esophagoscope  becomes 
essentially  airtight  and  the  esophagus  may  be  ballooned  at  will  by  clos- 
ing the  tube  with  the  window  plug  and  then  forcing  air  through  the 


Fig.   162. 

Mosher's  short  length  oval  esophagoscope.  This  tube 
is  11  inches  (28  cm.)  long,  and  :-4  inch  ( 1H  mm.) 
in  transverse  diameter.  The  cut  shows  the  mechanical 
device  which  locks  the  head  of  the  light  carrier  into  a 
notch  in  the  side  of  the  tube.  This  arrangement  holds 
the  carrier  firmly  in  place  and  allows  the  insertion  of 
the  air-tight  window  ping  in  the  mouth  of  the  tube.  The 
lower  end  of  the  light  carrier  passes  through  a  small 
ring  inside  the  oval  tube  and  near  the  lower  end.  (  Sec 
Fig.  163.) 


secondary  tube.  A.  stout  foot  bellows  is  used  for  this  purpose.  The 
light  carrier  runs  inside  of  the  main  tube,  and  as  it  is  not  incased 
in  a  small  tube  of  its  own  it  runs  freely  at  all  times.  (Figs.  Kil'-HiT. ) 
The  secondary  tube  for  the  light  carrier  is  bitten  and  dented  con- 
tinually so  that  the  light  enters  it  poorly.  'Flic  light  of  the  oval  tube 
is  incased  in  a  hood.  This  protects  it  during  insertion  and  while  the 
tube  is  in  use.  The  light  once  adjusted  in  its  hood  burns  much  longer 
than  when  it  is  exposed  to  the  dangers  of  passing  through  the  sec- 
ondary tube.  Each  tube  is  fitted  with  a  second  or  extra  carrier  so 
that  the  operator  seldom  has  the  annoyance  of  having  to  n't  a  new 
lamp  during  an  examination. 

The  General  Examination  of  the  Patient. — A  general  physical 
examination  of  the  patient  should  be  made  before  esophag- 
oscopy  is  attempted.  Aneurism  should  be  excluded  and  the 
condition  of  the  heart  ascertained.  The  patient's  ability  to  swallow, 


'2'2Q  OPERATIVE    STKCEHY    OF    THE    XOSE,    THROAT,    AND    EAR. 


Fig.  163. 


Fig.   164. 


Fig.  165. 


Fig.  166. 


Fig.  16:!. — .Moslicr's  esophagoscope  (short  length).  This  tube  is  made 
in  ;\vo  lengths — 11  inches  (L'8  cm.)  and  17  inches  ( 4'.'>  cm.) 

The  lower  figure  shows  the  method  of  holding  the  lower  end  of  the  light 
carrier  in  place  by  passing  it  through  a  small  ring  on  the  inside  of  the  main 
tube. 

Fig.  164.-  Hood  or  cap  which  protects  the  lamp.  This  arrangement  of 
the  light  carrier  the  author  has  found  more  satisfactory  than  the  accessory 
channel  on  the  outside  of  the  tube.  The  outside  channel  makes  a  rib  which 
on  large]-  tubes  tends  to  cut  the  soft  tissue.  The  outside  channel  is  con- 
stantly becoming  dented  so  that  the  light  carrier  runs  poorly  and  the  con- 
tact of  the  lamp  is  disturbed.  When  the  light  carrier  runs  inside  the  tube 
and  is  protected  by  the  hood  there  is  much  less  trouble  in  keeping  the  light 
in  good  condition. 

Fig.  16f>.--  Long  cunjcal  plunger  for  Mosher's  oval  esophagoscope. 
This  plunger  extends  beyond  the  end  of  the  tube  1  ' ._,  in.  This  plunger 
readily  enters  (he  esophagus  and  pries  the  cricoid  cartilage  forward  and 
allows  the  tube  to  follow  after  easily. 


six.es    of    .Mosher's    oval    esophagoscopes. 


LAKYNiiOSCOl'Y,     BHOXC  1 1  OSCOl'Y,     KS(  )IM  I  A<  IOS< '( >l'\  .     KT<   .  __1 

the  place  where  lie  locates  his  trouble,  and  all  the  details  about  rcgnrii-i- 
tation  or  vomiting  are  important  to  obtain.  The  condition  of  the  teeth 
is  observed  and  the  presence  of  crowns  or  bridges  noted  and  remem- 
bered. The  examination  of  the  month  and  pharynx  should  S!IO\Y  the 
existence  of  iilcerations  or  scars  and  the  laryngoscope  \vill  give  the  con- 
dition of  the  larynx.  If  disease  is  present  in  the  larynx  it  is  often  a 
part  of  a  similar  process  in  the  esophagus  or  a  clew  to  it.  An  X-ray 
plate  is  indispensable  before  many  examinations.  The  plate  sho\vs  the 
location  of  metallic  foreign  bodies  and  pieces  of  bone  and  buttons;  it 
shows  enlargement  of  the  arch  of  the  aorta  and  enlargement  of  the 
niediastinal  glands,  and  combined  with  the  ingestion  of  bismntli  it 
shows  the  position  of  strictures,  the  si/e  and  location  of  divertieiila, 
and  the  si/e  of  the  dilated  esophagus. 

The  old  practice  of  passing  a  bougie  into  the  esophagus  should  be 
in  Yen  up  in  most  cases.  It'  a  foreign  body  is  present  the  bougie  may 
push  it  down  or  impact  it  or  pass  by  and  fail  to  locate  it.  If  a  carci- 
noma is  present  it  will  start  bleeding  and  make  the  esophageal  exam- 
ination more  difficult.  Many  patients  have  been  killed  by  forcing  a 
bougie  through  the  carcinomatous  esophageal  wall.  If  the  physician 
is  dealing  with  a  case  of  cicatricial  stenosis  of  the  esophagus  or  a  ponch, 
the  bougie  is  safe  and  may  gi\'e  valuable  data.  This  information,  how- 
ever, is  much  better  gained  by  the  esophageal  examination  with  the 
tube. 

In  speaking  of  the  risks  of  esophagoscopy  it  was  stated  that  1  he 
greatest  danger  was  the  liability  of  perforating  the  esophagus.  This 
can  happen  before  the  examination,  as  well  as  during  it.  If,  therefore. 
a  case  presents  itself  for  examination  and  the  patient  has  great  pain 
on  swallowing  along  the  line  of  the  sternum,  if  the  respirations  are  in- 
creased, if  fever  is  present,  and  there  is  emphysema  <>f  the  skin,  tin- 
physician  should  suspect  that  the  esophagus  has  already  been  perfo- 
rated and  that  an  abscess  is  developing  in  the  mediastinum.  In  such 
a  case  drainage  of  the  abscess  is  indicated,  not  esophagoscopy. 

The  patient  should  be  examined  with  an  empty  stomach  and  if 
possible  with  an  empty  esophagus. 

The  ease  of  esophagoscopy  under  local  anesthesia  depends  upon 
the  tolerance  of  the  patient's  pharynx.  Briinings  has  a  long,  thin  tongue 
depressor  with  which  he  tests  the  sensitiveness  of  the  patient.  The 
first  introduction  of  the  cotton  swab  in  the  preliminary  application  of 
cocain  does  just  as  well  and  soon  settles  the  question  as  to  whether  or 
not  the  subject  is  an  intolerable  gagger.  The  experienced  examiner 
always  looks  with  anxiety  at  the  patient  's  neck  and  teeth.  If  the  upper 
jaw  does  not  project  and  if  the  teeth  are  short  or  better  still  if  there 


OPERATIVE    STRiiERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

are  no  upper  tooth,  if  tho  neck  is  long  and  thin  and  the  lower  jaw  well 
rounded  at  the  angle  and  freely  movable  the  chances  for  a  favorable 
examination  are  good.  AVhen  opposite  conditions  are  present  the  ex- 
amination is  often  difficult,  sometimes  impossible. 

Technic  of  Esophagoscopy  Under  Cocain  Anesthesia. — By  means 
of  an  appropriate  applicator,  that  of  Sajous  is  very  convenient,  a  ten 
per  cent  solution  of  oooain  is  applied  to  the  base  of  the  tongue  and  to 
the  posterior  pharyngoal  wall.  After  an  interval  of  a  few  minutes, 
under  guidance  of  the  laryngeal  mirror,  coeain  is  placed  on  the 
tip  of  the  epiglottis  and  allowed  to  run  into  the  larynx.  After  another 
interval  of  some  minutes  the  swab  is  carried  down  on  the  posterior 
pharyngoal  wall  to  the  opening  of  the  esophagus  and  applied  at  this 
point  and  to  the  region  of  the  arytenoid  cartilages.  It  is  well  to  repeat 
this  deep  cocainization  at  least  once.  It  takes  from  fifteen  to  twenty 
minutes  to  obtain  a  satisfactory  cocainization. 

Position  of  the  Patient. — The  patient  can  bo  examined  either  in 
the  sitting  position  or  on  his  back  with  tho  head  over  tho  end  of  the 
table  and  hold  by  an  assistant.  The  sitting  position  is  best  adapted  to 
short  examinations.  It  is  easier  for  tho  patient  especially  if  ho  is  old 
or  stout.  Where  it  is  essential  to  have  the  esophagus  clean  as  in  cases 
of  spasm  of  tho  cardia  with  dilatation,  stricture,  or  the  presence  of  a 
foreign  body,  as  well  as  with  children  or  weak  or  sick  patients,  the 
prone  position  is  preferable. 

If  the  sitting  position  is  adopted  the  patient  sits  on  a  low  stool 
25-.')0  cm.  in  height  and  an  assistant  stands  behind  him  and  holds  the 
head.  If  tho  patient  is  examined  on  a  table  he  may  be  placed  on  his 
back  or  on  his  side.  Of  tho  two  lateral  positions  the  left  is  the  easier 
because  the  physician  works  with  the  right-hand.  If  the  teeth  are 
missing  on  the  right  side  of  the  upper  jaw  the  right  lateral  position  is 
preferable.  If  the  incisor  teeth  have  been  lost  the  prone  position  is 
chosen.  This  position  is  selected  also  if  tho  operator  wishes  to  pass 
the  osophagoscopo  into  the  stomach  because  in  this  position  it  is  easier 
to  bring  the  shaft  of  the  osopliagoscopo  to  the  right  and  to  make  the 
point  enter  the  hiatus  of  the  diaphragm  and  to  traverse  the  subplirenic 
portion.  In  either  the  lateral  or  the  dorsal  positions  the  knees  are 
drawn  up  slightly  because  the  muscular  relaxation  caused  by  this 
makes  the  passage  of  the  tube  easier. 

The  Introduction  of  the  Esophagoscope  by  Sight.  The  ideal  way 
of  introducing  the  osophagosoope  is  to  insert  it  under  the  guidance  of 
the  eye.  'The  patient,  anesthetized  with  coeain,  is  placed  on  a  low 
stool,  and  an  assistant  stands  behind  him  and  holds  the  head,  ('arc 
-hoiild  be  taken  that  the  head  is  not  placed  too  far  back  as  oxces- 


LARYNGOSCOPY,    BKO.NC  I  losrol'V,    KSol'IIA<;os<  '<  >l'\  ,     KTr. 

sive  backward  bending  interferes  with  tlic  insertion  of  tin-  instrument. 
The  room  is  darkened  and  the  upper  part  of  the  extension  esophago- 
scope,  it'  tlie  Briinings  tube  is  chosen,  is  warmed  and  smeared  with 
vaseline  and  attached  to  the  electroscope.  The  operator  holds  the  up- 
per lip  of  the  patient  out  of  the  way  with  the  thumb  and  forefinger  of 
the  left  hand.  The  first  part  of  the  extension  csophagoscope  is  really 
an  elongated  tubular  speculum  ending  in  a  pointed  lip.  It  is. 
therefore,  introduced  like  the  autoscope.  That  is,  it  is  introduced  into 
the  mouth  and  steadied  by  the  tip  of  the  thumb  of  the  operator's  left 
hand  is  carried  back  over  the  base  of  the  tongue  until  the  summit 
of  the  epiglottis  is  seen  through  the  tube.  At  this  point  the  handle  of 
the  gastroscope  is  raised  and  the  lower  end  of  the  tube  is  passed  over 
the  epiglottis.  The  shaft  of  the  tube  is  elevated  until  it  lies  snugly 
against  the  physician's  forefinger  which  is  guarding  the  incisor  teeth 
or  the  gums  if  these  teeth  are  missing.  If  the  epiglottis  is  missed  the 
point  of  the  tube  is  almost  certain  to  bring  up  against  the  posterior 
pharyngeal  wall  much  to  the  discomfort  of  the  patient.  After  the  tip 
of  the  epiglottis  is  recognized  and  passed,  the  end  of  the  tube  is  car- 
ried down  until  the  arytenoid  cartilages  are  seen.  These  are  readily 
made  out  if  the  patient  is  asked  to  phonate.  The  point  of  the  tube  is 
now  swung  a  little  backward  to  clear  the  arytenoids  and  the  tube  is 
advanced  a  few  centimeters  to  the  opening  of  the  esophagus.  This  ap- 
pears as  a  transverse  slit.  The  end  of  the  tube  is  now  brought  forward 
a  bit  in  order  to  open  the  esophagus.  If  this  does  not  happen  the  patient 
is  almost  sure  to  swallow  and  when  he  does  so,  the  tube  slips  into  the 
esophagus.  Sometimes  the  patient  must  be  asked  to  swallow  before 
the  tube  will  drop  in.  In  difficult  introductions  the  point  of  the  tube 
may  be  placed  dee])  in  the  left  pyriform  sinus  and  then  swung  round  to 
the  median  line.  As  it  does  this  it  pries  the  cricoid  cartilage  forward. 
Once  past  the  cricoid  cartilage  the  progress  of  the  tube  is  easy.  The 
tube  is  now  carried  down,  advancing  slowly,  to  its  full  length,  the  ex- 
aminer all  the  while  guiding  the  point  by  looking  through  the  lube. 
The  tube  must  never  be  advanced  unless  the  esophagus  ahead  is  open 
to  receive  it.  When  the  tube  has  been  advanced  to  its  limit  the  second 
tube  is  inserted  inside  the  first  one  and  carried  down  by  sight.  When 
the  Jackson  tubular  speculum  is  used  for  the  introduction  of  the  eso- 
phagoscope  the  steps  are  the  same  as  for  the  first  Briinings  tube.  After 
the  mouth  of  the  esophagus  has  been  located  and  made  to  remain  open 
a  Jackson  esophagoscope  is  carried  through  the  speculum  and  into  the 
esophagus.  The  speculum  is  then  withdrawn. 

The  Introduction  of  the  Esophagoscope  by  Means   of   a   Flexible 
Mandarin  or  Bougie. — A  beaked,  partially  open  speculum    is    carried 


'2'24  OI'KRATIVK    Sl'HCKHV    OF    T1FK     XOSK.    THROAT,    AND    EAK. 

down  to  the  opening  of  the  esophagus  and  a  snugly  fitting  bougie  is 
passed  through  it  and  carried  into  the  esophagus.  The  speculum  is 
withdrawn  and  an  esophagoscope  is  passed  over  the  bougie  into  the 
esophagus.  This  procedure  which  often  makes  the  introduction  of 
the  tube  very  easy  should  never  be  used  when  it  is  the  purpose  of  the 
examiner  to  determine  the  condition  of  the  extreme  upper  end  of  the 
esophagus  or  when  a  foreign  body  is  impacted  in  this  locality.  Another 
method  of  using  the  bougie  as  a  guide  is  to  pass  a  Jackson  esophago- 
scope of  the  proper  si/e  below  and  behind  the  arytenoid  cartilages  and 
then  into  the  opening  of  the  esophagus.  A  bougie  is  then  passed 
through  the  tube  and  finally  the  tube  is  pushed  down  over  the  bougie. 
The  Introduction  of  the  Esophagoscope  Under  General  Anesthesia, 
-The  patient  is  prepared  for  ether  in  the  usual  way.  He  is  given  an 
injection  of  one  one-hundredth  of  a  grain  of  atropin  and  one-sixth  of 
a  grain  of  morphin.  The  atropin  produces  a  nearly  dry  esophagus  ex- 
cept in  those  instances  in  which  the  esophagus  is  dilaled  and  filled  with 
food  or  a  pouch  is  present  and  acts  as  a  reservoir.  A  suction  appar- 
atus is  not  usually  necessary,  but  is  always  a  great  luxury.  The  author 
is  using  il  more  and  more.  If  the  operator  works  sitting,  the  table  on 
which  the  patient  is  placed  should  be  of  the  proper  height  to  permit  the 
surgeon  to  work  at  ease.  If  the  operator  prefers  to  stand  the  table  should 
be  placed  on  a  platform  large  enough  to  hold  not  only  the  table  but  the 
stool  for  the  assistant  who  holds  the  head  and  for  the  etherizer.  The 
corner  of  the  platform  opposite  the  head  of  the  operating  table  is  cut 
out  to  allow  standing  room  for  the  operator.  During  the  examination 
should  it  become  advisable  to  lower  the  head  of  the  patient  the  oper- 
ator is  not  forced  to  work  on  his  knees.  An  assistant  holds  the  patient's 
head  over  the  end  of  the  table.  His  left  hand  supports  the  patient's 
head  and  his  left  knee  supports  his  hand  while  his  foot  rests  upon  a 
support  of  suitable  height.  The  assistant  should  so  grasp  the  head 
that  he  can  transfer  it  at  any  moment  to  the  physician,  be  ready  to  re- 
ceive the  head  hack  and  to  hold  it  in  the  new  position  indicated  by  the 
suru'eou.  Thus  the  patient's  head  is  continually  passing  from  the  hand 
of  the  assistant  to  that  of  the  operator.  It  is  vital  that  the  head  should 
not  be  extended  too  far  backward.  If  this  is  done  the  cricoid  cartilage 
is  held  ti.u'htly  against  the  sixth  cervical  vertebra  and  \vill  not  move 
forward  before  the  advancing  tube  without  the  application  of  great 
force.  A  rou.u'h  introduction  of  the  esophagoscope  may  cause  slough- 
in. u-  of  the  posterior  esophageal  wall.  This  may  have  a  disastrous  out- 
come in  a  weak  patient.  The  formation  of  the  mouth  of  the  esophagus 
caHs  for  another  word.  It  is  bounded  in  front  by  the  cartilaginous  ring 
of  the  cricoid  cartilage  and  behind  bv  the  bodv  of  the  sixth  cervical 


LARYNGOSCOPY,    BKONCIIOSCOPV,     KSOI'I  I  A<  iOSrol'Y,     K'I'C. 

vertebra.  Only  on  the  sides  where  the  pyriform  sinuses  lead  into  il  are 
tlie  walls  composed  of  soft  tissues.  The  natural  channel  for  food  into 
the  esophagus  is  by  way  of  the  pyrifonn  sinuses  and  experience  has 
shown  that  the  pyrifonn  sinus  is  the  natural  and  the  easiest  channel 
through  which  to  pass  the  esophagoscope.  If  the  tube  chosen  for  the 
introduction  into  the  esophagus  will  not  pass,  the  operator  should  at 
once  select  a  smaller  tube  until  one  is  found  which  will  enter  without 
being  forced.  The  tubes  which  are  most  useful  according  to 
Bru'Miiigs  are  10,  12,  and  14  nun.  Practically  every  patient  will  admit 
a  tube  of  one  size  or  another  unless  the  body  of  the  sixth  cervical  verte- 
bra is  enlarged,  or  the  cervical  vertebne  are  diseased. 

It  is  usually  possible  to  pass  the  tube  by  sight  and  this  method 
should  be  attempted  first.  Suppose  the  Jackson  instruments  are  se- 
lected. The  procedure  of  introducing  the  esophagoscope  by  sight  is 
as  follows.  If  the  teeth  are  intact  or  if  they  consist  chiefly  of  stumps 
those  of  the  upper  jaw  are  protected  by  inserting  a  thin  aluminum  tooth 
plate.  If  the  gums  are  bare  of  teeth  the  use  of  the  tooth  plate  is  just 
as  important  for  the  later  comfort  of  the  patient.  Tn  a  hard  introduc- 
tion, no  matter  which  instrument  is  used,  the  tooth  plate  should 
be  employed  until  the  tube  is  well  in  the  esophagus  because  notwith- 
standing assertions  to  the  contrary,  teeth  may  be  nicked,  broken  or 
forced  from  their  sockets.  Patients  do  not  readily  forget  such  an  oc- 
currence. The  teeth,  then,  have  been  protected  with  a  tooth  plate  and 
the  assistant  holds  the  head  bent  backward  moderately.  The  jaws  are 
kept  slightly  apart  by  a  gag  placed  in  the  left  corner  of  the 
mouth.  The  tongue  is  made  to  lie  naturally  and  the  end 
of  the  tubular  speculum  is  carried  along  the  central  furrow 
of  the  tongue,  and  is  pushed  forward  and  downward  until  the 
tip  of  the  epiglottis  is  recognized.  The  tip  of  the  epiglottis  and  then 
the  body  of  the  epiglottis  are  picked  up  by  the  end  of  the  speculum  in 
turn  and  drawn  forward  until  the  arytenoids  appear.  These  in  turn 
are  passed  by  inserting  the  point  of  the  speculum  behind  them  and 
forcing  them  forward,  and  the  speculum  is  carried  still  further  down. 
All  the  time  the  operator  is  making  traction  forward.  AVhen  the  proper 
depth  has  been  reached  the  back  of  the  cricoid  cartilage  is  encountered 
and  this  like  the  structures  above  is  pushed  forward.  At  this  point 
the  mouth  of  the  esophagus  opens  and  the  operator  looks  into  the  lu- 
men of  the  esophagus  for  a  considerable  distance.  In  favorable  cases, 
especially  in  infants  and  children,  he  can  see  down  the  esophagus  al- 
most to  the  inner  end  of  the  clavicles.  AVith  the  cricoid  cartilage 
drawn  forward  and  the  mouth  of  the  esophagus  gaping  it  is  a  simple 
matter  to  pass  the  esophagoscope  through  the  tubular  speculum  into 
the  esophagus,  to  remove  the  slide  and  to  withdraw  the  speculum.  In- 


'2'26  OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 

troduction  by  sight  is  the  ideal  method,  because  in  this  procedure  there 
are  no  blind  points.  It  is  not  necessary  to  describe  the  introduction  by 
sight  of  the  Briinings  extension  esophagoscope.  The  first  part  of  his 
double  tube  takes  the  place  of  the  Jackson  tubular  speculum  and  is 
used  in  the  same  manner.  After  the  esophagoscope  has  been  inserted, 
if  the  purpose  of  the  examination  is  to  explore  the  whole  length  of  the 
esophagus,  pathologic  conditions  permitting,  the  tube  is  swung  to  the 
corner  of  the  mouth  on  the  right.  If  any  teeth  are  fortunately  missing 
on  this  side  the  barrel  of  the  esophagoscope  is  made  to  lie  in  the  tooth 
gap.  Should  it  happen  that  the  missing  teeth  are  on  the  left  side  and 
the  introduction  difficult  it  is  well  to  shift  the  tube  to  the  left  corner  of 
the  mouth. 

The  Use  of  the  Adjustable  Speculum  for  the  Introduction  of  the 
Esophagoscope. — The  author  has  for  some  years  worked  with  his  open 
and  adjustable  speculum  for  the  examination  of  the  upper  end  of  the 
esophagus  and  for  the  introduction  of  the  esophagoscope.  The  spec- 
ulum is  an  adjustable  tubular  speculum  with  the  right  side  cut  away. 
Owing  to  this  fact  all  the  landmarks  of  the  pharynx  and  larynx  can  be 
seen  ahead  of  the  speculum  and  in  their  proper  perspective.  There  is 
a  large  lateral  excursion  for  the  eye,  which  reduces  the  eye  strain,  and 
makes  the  introduction  of  the  tube  easier  thus  giving  a  greater  play 
for  instrumentation  about  the  arytenoids,  in  the  pyriform  sinus  and  in 
the  upper  part  of  the  esophagus.  The  speculum  is  introduced  in  the 
same  manner  as  the  tubular  speculum  of  Jackson.  Should  the  purpose 
of  the  examination  be  to  examine  the  esophagus  below  the  clavicles,  the 
cricoid  cartilage  is  pulled  forward,  the  upper  portion  of  the  esophagus 
is  exposed,  and  then  the  esophagoscope  is  passed  by  sight  through  the 
speculum  into  the  esophagus  and  the  speculum  taken  out.  The  tooth 
plate,  if  it  has  been  used,  is  retained  or  not  at  the  discretion  of  the 
examiner. 

Passing  the  Jackson  Esophagoscope  by  Sight. — The  .Jackson 
esophagoscope  can  often  be  passed  by  sight,  especially  if  a  lube  of  mod- 
erate size  is  selected.  The  manipulations  are  the  same  as  in  the  intro- 
duction of  the  tubular  speculum.  The  field  given  by  the  esophagoscope 
is  of  course  somewhat  smaller  than  that  which  is  given  by  the  tubular 
speculum.  This  difference  in  an  easy  examination  amounts  to  nothing. 
When  the  esophagoscope  has  been  passed  by  sight  to  the  arytenoid 
cartilages  the  point  is  swung  to  1  he  right  into  the  pyriform  sinus  and 
entered  deeply  at  this  point.  When  it  reaches  bottom,  so  to  speak,  the 
point  is  swung  back"  to  the  middle  line.  As  this  occurs  the  tube  forces 
the  cricoid  cartilage  forward  and  slips  into  the  mouth  of  the  esophagus. 

Passing  the  Oval  Tube  by  Sight.  As  the  author  has  done  prac- 
tically all  his  work'  upon  the  esophagus  under  ether  anesthesia,  he  pre- 


LAKYXliOSCOl'Y,     MHOXC  H  OSCOI'Y,     KS<  II'  1 1  A<  i<  )SC(  >\>\  ,     KTC. 


fers  to  use  for  the  esophageal  cxainiiiatioii  as  large  a  tube  as  the  eso- 
phagus can  be  made  to  lake.  Oval  lubes  lake  up  the  slack  of  tlie  eso- 
phagus along  anatomic  lines  belter  than  round  ones.  For  this  reason 
the  writer  employs  large  oval  tubes.  These  are  made  in  two  leim'th^ 
an  eleven-inch  tube  and  an  eighteen-inch  tube.  So  many  of  the  path- 
ologic conditions  of  the  esophagus  are  found  in  the  upper  part  and  the 
eye  strain  is  so  vastly  increased  by  looking  through  a  long  tube  that 
it  is  economy  of  eyesight  to  have  tubes  of  two  lengths.  The  short  oval 
tube  is  selected  and  passed  by  sight  to  the  right  pyriform  sinus.  At 
this  point  the  transverse  axis  of  the  tube  is  made  to  lie  anteriorly  by 
rotating  the  tube  to  the  right.  The  tube  will  then  sink  further  into 
the  sinus.  AVhen  the  point  of  the  tube  is  as  far  in  the  pyriform  sinus 
as  it  will  go  without  being  forced,  the  tube  is  rotated  back  to  its  orig- 
inal position  with  the  long  axis  again  transverse.  As  this  manipula- 
tion is  carried  out  the  left  edge  of  the  oval  tube  insinuates  itself  behind 
the  body  of  the  cricoid  cartilage  thus  pushing  it  forward,  and  the  tube 
enters  the  esophagus.  All  these  manipulations  are  seen  by  the  exam- 
iner as  he  guides  them  through  the  tube.  The  field  which  the  large 
tube  gives  is  so  superior  to  that  afforded  by  a  round  and  smaller  tube 
that  every  legitimate  effort  should  be  made  to  introduce  as  large  a  tube 
into  the  esophagus  as  will  pass  the  cricoid  cartilage-.  Even 
a  large  oval  tube  seems  too  small  for  the  calibre  of  the  esophagus  once 
the  cricoid  cartilage  has  been  passed.  The  examiner  gets  this  impres- 
sion even  in  the  normal  adult  esophagus,  to  say  nothing  of  the  dilated 
esophagus  of  cardiospasm. 

The  Passing  of  the  Esophagoscope  by  Aid  of  a  Mandarin  or  a 
Flexible  Bougie. —  In  the  early  days  of  the  esophagoscope  it  was 
almost  always  introduced  by  means  of  a  projecting  plunger  or  man- 
darin. At  first  the  mandarin  had  a  rigid  end;  later  flexible  tips  were 
added.  To  all  intents  and  purposes  the  elastic  bougie  is  a  mandarin 
with  a  flexible  tip  and  is  so  used  today.  The  mandarin  is  ehielly  em- 
ployed with  the  finger  tip  introduction  of  the  esophagoscope  or  the 
gastroscope.  There  is  no  great  or  vital  objection  to  the  use  of  the 
mandarin  if  the  examiner  is  sure  that  the  pathologic  condition  is  well 
down  the  esophagus  or  if,  as  in  gastroscopy,  he  is  to  pass  the  tube 
through  a  normal  esophagus.  The  procedure  is  carried  out  as  follows: 
The  examiner  holds  the  esophagoscope  in  the  right  hand  and  with 
his  thumb  steadies  the  head  of  the  plunger.  With  the  forefinger  of 
the  left  hand  he  feels  the  right  arytenoid  cartilage  by  forcing  his  finger 
well  down  the  patient's  pharynx.  Along  the  inner  surface  of  the  left 
forefinger  of  the  examiner  the  esophagoscope  is  carried  into  the  ri.u'ht 
pyriform  sinus.  When  the  end  of  the  instrument  has  reached  this 


228  Ol'KHATIYE    SUH(iEHV    OF    THE    NOSE,    THROAT,    AND    EAR. 

point  a  little  twist  of  the  end  of  the  tube  to  the  left  carries  the  tube  into 
the  esophagus.  With  a  tube  of  medium  or  small  diameter  this  method 
of  introduction  is  the  quickest  and  easiest.  The  disadvantage  of  the 
procedure  need  not  be  dwelt  upon  after  wliat  has  been  said  of  the  ad- 
vantage of  the  introduction  by  sight.  The  largo  oval  tube  which  is 
used  by  the  author  is  fitted  with  a  conical  rigid  plunger  which  projects 
from  the  end  of  the  tube  an  inch  and  a  half.  The  plunger  is  used 
in  those  cases  in  which  the  ocular  introduction  of  the  oval  tube  does 
not  succeed.  The  oval  tube  is  carried  down  by  sight  and  the  attempt 
is  made  to  pass  it  by  sight  after  the  method  which  lias  just  been 
described.  If  this  fails  the  plunger  is  put  in  and  gently  forced  home. 
The  plunger  is  so  long  and  pointed  that  it  finds  its  way  behind  the 
cricoid  cartilage,  dislocates  it  forward  and  allows  the  tube  to  follow 
on  after  it. 

The  introduction  of  the  esophagoscope  with  flexible  bougies  is 
best  adapted  to  round  tubes.  The  bougie  can  first  be  introduced  by 
the  finger  tip  method  or  the  tube  can  be  carried  to  the  entrance  of  the 
esophagus  by  sight  and  then  the  bougie  passed  through  it  and  into  the 
esophagus.  The  tube  may  then  be  slipped  down  over  the  bougie. 

The  impression  may  have  been  given  by  what  has  been  said  con- 
cerning the  introduction  of  large  tubes  that  they  should  be  used  at 
all  costs.  This  is  not  the  impression  \vliich  the  author  wishes  to  leave. 
If  a  large  tube  can  be  used,  and  it  can  be  used  under  ether  without 
danger  oftener  than  is  generally  recognized,  it  should  be  employed.  It 
must  be  remembered,  however,  that  if  the  introduction  of  a  chosen  tube 
is  not  easily  successful,  that  tube  should  be  discarded  at  once  for  a 
smaller  one.  Obstinacy  on  this  point  will  lead  to  disaster. 

The  Appearance  of  the  Normal  Esophagus. — Under  good  illumina- 
tion the  color  of  the  mucous  membrane  of  the  esophagus  is  a  whitish 
pink  like  that  of  the  mouth.  Poorly  lighted  or  when  inflamed  the  color 
changes  to  a  red  of  varying  depth.  After  trauma,  the  mucous  mem- 
brane soon  becomes  edematous.  When  examined  with  small  tubes  the 
walls  of  the  esophagus  are  thrown  into  large  longitudinal  folds,  and  on 
looking  through  the  tube  they  are  seen  indenting  the  circumference 
of  the  central  dark  area  which  represents  the  lumen  of  the  esophagus. 
These  folds  are  especially  numerous  at  the  mouth  of  the  esophagus 
behind  the  cricoid  cartilage.  They  make  it  hard  to  be  sure  of  the  path- 
ologic lesions  in  this  locality.  Below  the  criroid  cartilage  and  in  the 
cervical  region  the  lumen  is  seen  to  enlarge1  with  inspiration  and  to 
close  down  again,  but  not  entirely,  during  expiration.  When  a  large 
tube  is  used  the  examiner  can  often  look  down  the  esophagus  a 
long  way  ahead  of  it.  As  the  esophagoscope  reaches  the  first 


L,AKY\<;OS<'0|>V,     BliONC  IIOSC'OI'V,     KSOl'll  A<;osro|'\  ,     K'I'C. 


piece  of  the  sternum  the  pulsation  of  the  arch  of  the  aorta  can  be  >een 
1 hrough  the  anterior  wall.  A  little  lower  the  heart  mounds  into  tli<- 
anterior  wall  on  the  left.  The  beating  of  the  heart  is  visible  an<l  when 
the  tube  has  passed  beyond  and  the  heart  lies  against  it,  the  tube  often 


Fig.   ItiH. 


Fig.  170. 


Fig.    171. 


Fig.  168. — The  normal  esophagus  above  the  hiatus  of  the  diaphragm, 
and  with  the  diaphragm  contracted. 

Fig.  Kilt. — The  esophagoscope  has  been  pushed  through  the  hiatus  of 
the  diaphragm  and  entered  the  subphrenic  portion  of  the  esophagus.  The 
characteristic  longitudinal  folds  of  this  part  of  the  esophagus  are  shown. 
They  converge  to  the  left  upon  an  ill-defined  transverse  slit  which  is  the 
cardiac  opening. 

Fig.  170. — The  esophagoscope  has  been  carried  through  the  cardiac  open- 
ing of  the  esophagus  into  the  stomach.  The  stomach  appears  as  a  funnel- 
shaped  cavity.  On  the  lower  wall  of  this  the  ruga>  of  the  stomach  are  seen. 

Fig.  171. — The  drawing  shows  the  esophagus  just  above  the  hiatus  of 
the  diaphragm.  The  patient  was  examined  under  ether  and  with  an  oval 
esophagoscope.  On  the  patient's  right  the  rim  of  the  hiatus  is  partially 
contracted  and  mounds  into  the  lumen  of  the  esophagus.  Later  in  the  ex- 
amination when  the  diaphragm  became  fully  relaxed  this  ridge  dis- 
appeared. I5elow  and  beyond  the  ridge  the  subphrenic  portion  of  the 
esophagus  is  seen.  The  characteristic  longitudinal  folds  veer  to  the  left 
and  end  in  the  cardiac  opening.  The  cardiac  opening  is  in  a  state  of 
spasm. 

(Drawings  by  the  author) 

vibrates  in  unison  with  the  heart  beat.  The  hiatus  of  the  esophagus 
appears  as  a  slit  or  a  rosette.  'Phe  axis  of  this  opening  through  the 
diaphragm  is  oblique,  running  from  right  to  left,  from  behind  forward. 
The  subphrenic  portion  of  the  esophagus  usually  shows  no  lumen,  but 


230 


OPERATIVE    SUROERY    OF    THE    XOSE,    THROAT.    AND    EAR. 


Fig.   172. 


Fig.   173. 


Fig.  174. 


Fin.   17*;. 


Fig.  175. 


Fig.   1' 


Fig.   17.!.  Normal    esophagus    during    quiet     breathing.      Small     esopha- 

goscope. 

Fig.   17!..  Normal    esophagus   during   deep    respiration. 

Fig.   174.  Stricture  of  esophagus   with   scars   radiating    from    its   lumen. 

Figs.    17.~i  and    17(>. —  Carcinoma    of  the  esophagus. 

Fig.    177.  Fish    bone    in    the   esophagus. 
(After  Stark.  I 


L,ARYN(JOSC()1JY,    BRONC1  tOSCOI'V,     KSOPir.UiOSCOI'Y,     KTC.  Ll.'il 

opens  as  the  tul)c  passes  through  it.  Tlie  mucous  membrane  of  this 
part  is  so  much  like  that  of  the  stomach  that  il  is  hard  to  tell  where 
the  esophagus  ends  and  the  stomach  begins.  The  mucous  membrane 
of  the  stomach,  however,  is  a  darker  red  than  that  of  the  esophagus  and 
the  longitudinal  folds  of  the  esophagus  give  place  to  the  familial1  rouge. 

The  mouth  of  the  esophagus  and  the  hiatus  are  the  two  places 
where  it  is  always  difficult  for  the  examiner  to  be  sure  of  his  findings. 
The  difficulty  at  the  first  place  is  due  chiefly  to  the  folds  of  the  mucous 
membrane.  These  can  be  stretched  out  by  passing  the  esopha- 
geal  dilator  well  into  the  mouth  of  the  esophagus  and  opening  it  suffi- 
ciently to  displace  the  cricoid  cartilage  strongly  forward.  If  a  true 
web  is  suspected  the  withdrawal  of  the  open  dilator  will  make  its  size 
and  position  plain.  The  introduction  of  a  small  tube  through  the  pyri- 
form  sinus  is  very  liable  to  push  a  fold  of  the  mucous  membrane  ahead 
of  it  and  produce  an  artificial  web  or  fold.  Once  the  cricoid  cartilage 
has  been  passed  the  further  progress  of  the  esophagoscope  is  usually 
easy.  The  examiner  should  always  see  the  open  esophagus  ahead 
through  the  tube  before  the  tube  is  advanced.  When  no  lumen  appears 
the  end  of  the  tube  is  generally  pointed  too  much  to  the  side  and  is 
out  of  line  with  the  long  axis  of  the  esophagus.  If,  on  correcting  the 
position  of  the  tube,  the  lumen  of  the  esophagus  is  still  unnoticeable, 
its  position  can  be  made  out  by  inserting  the  window  plug  and  filling 
the  esophagus  with  air.  The  author  considers  this  expediency  of  the 
utmost  value.  Once  the  lumen  has  been  found  the  tube  can  be  carried 
further  down. 

In  order  to  enter  the  hiatus  it  is  necessary  to  carry  the  shaft  of  the 
esophagoscope  to  the  right  corner  of  the  mouth  and  the  point  of  the 
tube  to  the  left,  beginning  the  search  in  the  right  posterior  quadrant 
of  the  esophagus.  It  is  at  this  point  that  the  hiatus  is  most  readily 
found.  When  the  point  of  the  tube  cannot  be  made  to  enter  the  hiatus 
and  to  proceed  through  the  kinked  subphrenic  portion  of  the  esopha- 
gus, a  bougie  passed  through  the  esophagoscope  and  into  the  sub- 
phrenic  portion  will  often  guide  the  tube  into  the  stomach.  The  author 
relies  upon  ballooning  the  esophagus  and  thus  finding  his  way.  After 
the  esophagus  has  been  examined  all  the  way  to  the  stomach  the  tube 
is  withdrawn  and  the  whole  of  the  esophageal  wall  is  reexamined. 

THE   DISEASES   OF    THE    ESOPHAGUS. 

The  chief  symptom  of  disease  of  the  esophagus  is  obstruction  to 
swallowing.  Diseases  of  the  esophagus,  therefore,  fall  into  two  groups, 
those  which  cause  marked  stenosis  and  those  which  do  not.  Xew 
growths  form  an  important  subgroup.  As  elsewhere  in  the  body  a  new 


OPERATIVE    STHCKKV    OF    TIIK    XOSK,    THROAT.    AND    HAH. 

growth  may  he  benign  or  malignant.   Foreign  bodies  in  the  esophagus 
make  the  final  important  group  to  he  considered. 

DISEASES   OF   THE    ES()PHA(U'S   AYIIICH    CATSE   STENOSIS. 

Acute  Inflammation. 

Following  the  swallowing  of  a  corrosive  such  as  lye  (washing 
powders),  carholic  acid,  or  corrosive  sublimate,  the  esophagus  becomes 
acutely  inflamed  and  more  or  less  completely  closed.  Rough,  impacted 
foreign  hodies  also  cause  a  local  inflammation.  This  may  he  more  or 
Jess  general  if  the  foreign  hody  has  caused  extensive  trauma. 

After  the  swallowing  of  a  caustic  it  is  hetter  to  wait  for  a  few  weeks, 
perhaps  a  month  or  two  until  the  inflammatory  disturbance  has  sub- 
sided before  examining  the  esophagus  with  the  esophagoscope  or  be- 
fore passing  bougies  by  the  aid  of  the  esophagoscope  in  the  hope  of 
preventing  the  formation  of  cicatricial  strictures.  This  caution  is 
especially  necessary  in  dealing  with  young  children.  In  such  cases  it  is 
probably  better  to  open  the  stomach  without  delay  and  to  nourish  the 
child  through  the  gastric  fistula  until  it  has  regained  its  powers  of 
resistance  and  is  once  more  well  nourished.  If  a  foreign  body  has 
caused  the  inflammatory  stenosis  of  the  esophagus,  i1  must  be  removed 
at  once. 

Stenosis  of  the  Esophagus  Due  to  Cicatrices. 

Cicatricial  stenosis  of  the  esophagus  may  be  the  result  of  opera- 
tion, i.  e.,  removal  of  the  glands  of  Ihe  neck,  or  excision  of  the  larynx. 
Traumatic  stenoses  are  caused  by  gunshot  wounds  and  by  swallowing 
sharp  foreign  bodies.  Systemic  diseases  which  are  at  times  associated 
with  ulcerations  of  the  esophagus  may  also  cause  cicatricial  stenoses. 
Syphilis  and  typhoid  fever  are  occasionally  responsible  for  such  stric- 
tures. Pneumonia  may  produce  the  same  condition,  but  cicatricial 
strictures  are  most  common  after  the  swallowing  of  some  escharotic. 
When  home-made  soap  was  common,  children  drank"  it  by  mistake. 
Today  they  drink  solutions  of  corrosive  sublimate,  which  are  kept  to 
destroy  vermin,  or  the  various  washing  compounds  containing  caustic 
soda. 

It  may  he  years  before  cicatrieial  strictures  finally  shut  down. 
Adult  patients  not  infrequently  present  themselves  who  give  a  history 
of  having  swallowed  some  caustic  in  childhood  and  who  have  had  only 
moderate  difficulty  in  swallowing  for  years. 

The  Location  of  Strictures.  Caustic  strictures  form  most  readily 
at  the  points  where  the  esophagus  is  the  narrowest.  They  are  found, 
therefore,  most  commonly  at  the  upper  or  lower  end  of  the  esophagus. 


I.ARYXOOSCOI'Y,     BHONTIIOSCOPY,     KSOIMI  A<  JOSCOl'Y,     KTC. 

Occasionally  a  stricture  is  found  at  the  level  of  the  clavicles.  Xot  un- 
commonly there  \vill  l)e  a  stricture  at  the  level  of  the  clavicles  and  a 
second  and  larger  one  at  the  cardiac  end  of  the  esophagus.  The  usual 
tight  stricture  is  about  an  inch  long.  At  times  the  whole  lower  half 
of  the  esophagus  is  narrowed,  making  one  long  strict  lire.  The 
author  met  this  condition  once  as  the  result  of  ulcerations  of  the  mouth, 
pharynx  and  esophagus  during  pneumonia.  Partial  hand-like  stric- 
tures may  precede  and  guard  the  opening  of  the  chief  stricture.  The 
esopliageal  wall  above  a  stricture  is  dilated.  This  sac-like  pouch  en- 
gages the  end  of  a  bougie  and  keeps  it  from  finding  the  lumen  of  the 
stricture  easily.  \Ylien,  however,  the  esophagus  is  examined  with  the 
esopliagoscope,  especially  if  a  tube  of  good  si/e  is  used,  the  lumen  of 
the  sti'icture  is  easily  made  to  come  opposite  the  end  of  the  tube.  (Fig. 
176.) 

The  Diagnosis  and  Treatment  of  Esophageal  Strictures.—  Tin-  best 
method  of  determining  the  presence  of  an  osophagoal  sti'icture  is  to 
pass  the  esophagoseope.  The  larger  the  examining  lube  the  easier  it 
is  to  find  the  constriction  and  to  make  the  lumen  of  the  stricture  center 
with  the  end  of  the  tube.  The  mere  presence  of  a  stricture  can  be  made 
out  with  a  small  tube  and  the  examination  carried  on  under  eocain 
anesthesia.  The  accurate  mapping  out  of  a  stricture,  however,  and  its 
maximum  dilatation  are  possible  only  under  general  anesthesia.  For 
this  reason  the  author  feels  that  time  is  wasted  in  examining  a  cica- 
tricial  stricture  under  local  anesthesia.  When,  therefore,  a  patient  is 
to  be  examined  for  a  cicatricial  stricture  he  should  be  etheri/.ed  and 
placed  on  the  examining  table  with  the  head  hanging  over  the  edge 
and  as  large  a  tube  introduced  as  can  be  made  to  pass  the 
cricoid  cartilage  easily.  Under  direct  vision  the  tube  is  carried  down 
to  the  stricture  and  the  lumen  of  the  stricture  made  to  correspond  with 
the  center  of  the  tube.  The  author's  experience  lias  been  that  this  is 
easy  to  accomplish.  Occasionally  ballooning  the  esophagus  with  air 
helps  to  find  the  opening  of  the  sti'ictui'e.  After  the  dilatation  of  a 
Miiall  stricture  has  been  begun  the  ballooning  is  an  easy  way  of  keep- 
in, u1  the  blood  out  of  the  mouth  of  the  stricture.  To  return,  after  the 
sti'ictui'e  has  been  found  and  its  opening  centered  at  the  end  of  the 
tube,  the  lumen  of  the  stricture  should  be  tested  with  an  elastic  bougie 
of  appropriate  size.  If  it  happens  that  the  lumen  measures  2<)  F.  or  is 
easily  dilatable  with  soft  bougies  up  to  this  calibre,  the  metal  dilator 
(Fig.  178)  is  carried  by  sight  through  the  stricture  and  the  dilating 
mechanism  expanded  until  marked  resistance  is  felt.  The  dilator  is 
kept  expanded  for  two  or  three  minutes  and  then  closed.  After 
a  short  interval  the  stricture  is  again  put  on  the  stretch.  P>y  coaxinu1 


2:!4 


OPERATIVE    sriUlERY    OF    THE    NOSE,    THROAT,    AND    EAR. 


the  dilatation  a  marked  gain  in  the  lumen  of  the  stricture  is  soon  at- 
tained. It  is  surprising  how  readily  even  old  strictures  will  yield.  The 
author  so  far  has  not  found  it  necessary  to  cut  a  stricture  in  order  to 
make  dilatation  possible.  Xo  rule  can  be  given  as  to  how  fast  to  dilate 
or  how  much.  Until  more  data  have  been  accumulated  upon  this  point 
the  operator  must  use  his  best  judgment.  The  aim  is  to  get  the  max- 
imum dilatation  so  that  a  good  sized  bougie  can  be  passed  easily  after 
the  examination.  In  a  bov  of  seven  vears  with  a  vear  old  corrosive 


luiiimiiaiiiiiiiiuiiJiiiiiJiJiiiiiiiiJiiiiiiiiiiiiiiiiiiiniifiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiftiiiiirp"""1'""'"""' 


Fig.  178. 

Mosher's  mechanical  dilator,  with  two  tips.     A,  tip  for  use  in  stricture 
of  the  esophagus;   B,  tip  with  larger  expansion  for  use  in  cardiospasm. 

stricture  which  would  not  admit  a  16  F.  bougie  without  ether  and  in 
whom  under  ether  a  20  F.  passed  firmly,  1  was  content  with  a  dilatation 
to  .'54  V.  In  a  woman  of  forty  with  a  stricture  which  had  existed  since 
childhood  and  which  admitted  without  ether  a  number  20  V.  bougie 
with  difficulty,  the  dilatation  was  carried  carefully  up  to  42  F.  This 
was  sufficient  to  allow  the  passage  after  ether  of  a  -'!2  F.  bougie.  The 
dilatation  was  subsequently  increased  by  the  weekly  passing  of  elastic 
bougies  up  to  .'Hi  F.  Rapid  dilatation  under  ether  saves  months  of 


Fig.   17!). 

Modified    limit's   olive-tipped    metal    bougie.      This   instrument    is    used 
for   starting   the   dilatation    of   small    strictures   of   the   esophagus. 

Iv\ per ic nee  has  proved  1  hat  rapid  dilatation  is  safe  if  carried  out 
wit  h  ordinary  caution. 

In  the  treatment  of  strictures  in  which  the  lumen  is  so  small  that 
the  smallest  elastic  bougies  will  not  pass,  much  can  be  accomplished 
by  the  gentle  use  of  a  staff  carrying  small  metal  olives  (  Kig.  17!)).  With 
the  smallest  olive  an  eighth  or  a  quarter  of  an  inch  of  the  stricture  is 
picked  or  teased  open.  After  this  an  elastic  bougie  of  slightly  larger 
si/e  is  introduced  in  the  hope  of  increasing  the  dilatation.  The  use  of 


LAKYNdOSCOPY,     BRONCHOSCOPY,     F.SOPH  AOOSCOPY,     KTC.  -'•}'•) 

the  metal  olive  should  he  most  guarded.  All  the  while  the  operator 
must  be  conscious  of  the  true  axis  of  the  esophagus  because  any  devi- 
ation from  the  proper  line  will  result  in  a  perforation  and  the  probable 
death  of  the  patient.  In  long  tight  strictures  it  is  not  necessary  that 
the  lumen  be  restored  through  the  whole  length  of  the  stricture  at  the 
first  sitting,  because  experience  lias  proved  that  it  is  better  in  such  cases 
to  open  the  stomach  at  once  and  to  get  the  patient  properly  nourished 
before  very  tight  or  very  long  strictures  are  dilated.  When  an  emaci- 
ated, half-starved  patient  presents  himself,  and  especially  in  the  case 
of  children,  it  is  better  surgery  to  open  the  stomach  at  once  and  to 
restore  the  patient's  resistance  by  feeding  before  attempting  the  dila- 
tation of  a  difficult  stricture.  If  this  has  been  done  there  is  no  hurry 
so  that  the  stricture  may  be  opened  up  gradually. 

The  following  histories  are  given  as  illustrations  of  typical  cases 
of  stricture: 

Case   Number  1. 

A  boy  two  years  old  drank  a  caustic  solution  and  three  months  later  developed 
marked  difficulty  in  swallowing.  Milk  became  his  only  food.  One  day  this  would  stay 
down,  the  next  the  greater  part  of  the  milk  would  be  regurgitated  soon  after  it  was 
swallowed.  A  number  16  F.  elastic  bougie  met  with  resistance  at  the  lower  end  of  the 
esophagus  and  would  not  enter  the  stomach. 

Under  ether  a  stricture  was  found  at  the  cardiac  end  of  the  esophagus,  and  a 
moderate  dilatation  of  the  esophagus  above  it.  The  stricture  proved  to  be  an  inch  long. 
It  dilated  readily  with  elastic  bougies  to  20  F.  From  this  measurement  the  dilatation 
svas  carried  to  32  F.  with  the  mechanical  dilator.  As  was  just  said  it  was  impos- 
sible to  pass  even  a  small  bougie  into  the  boy's  stomach  before  the  etherization  and 
dilatation,  but  afterwards  a  number  32  F.  could  be  introduced  easily.  The  family  phy- 
sician passed  a  number  32  F.  bougie  once  a  week.  The  boy  soon  became  well  nour- 
ished again.  At  the  end  of  a  year  and  a  half  the  mother  of  the  child  reported  that  he  had 
no  difficulty  in  swallowing. 

Case   Number  2. 

A  woman  in  the  forties  gave  a  history  of  marked  difficulty  in  swallowing  for  two 
months,  and  of  pain  in  the  epigastric  region.  She  was  moderately  well  nourished  and 
was  living  on  milk  and  soft  solids.  The  patient  stated  that  when  she  was  a  small  child 
a  playmate  offered  her  a  drink  of  vitriol.  Since  this  happening  she  had  had  a  moderate 
and  stationary  amount  of  trouble  with  swallowing.  For  the  last  month,  however,  the 
trouble  had  suddenly  increased  and  she  had  begun  to  have  pain  in  the  region  of  the 
stomach. 

A  number  20  F.  bougie  encountered  resistance  at  the  cardiac  end  of  the  esopha- 
gus and  entered  the  stomach  with  difficulty.  The  X-ray  showed  that  the  lower  half  of 
the  esophagus  was  narrowed. 

The  ether  examination  disclosed  a  stricture  at  the  level  of  the  clavicle.  The 
lumen  of  this  was  about  30  F.  This  stricture  was  easily  dilated  with  the  mechanical 
dilator  so  that  it  permitted  the  passage  of  a  tube  measuring  half  an  inch.  A  second 
stricture  was  found  at  the  cardiac  end  of  the  esophagus.  The  second  and  lower  stric- 
ture was  dilated  with  elastic  bougies  up  to  22  F.  and  then  the  mechanical  dilator  w?.j 
introduced  and  the  stricture  stretched  slowly  and  at  intervals  of  a  few  minutes  up  to 
a  final  dilatation  of  42  F.  At  this  point  the  resistance  to  the  dilatation  became  extreme 
and  it  was  discontinued. 


OPERATIVE    SUKCEKY    OF    THE    NOSE,    THROAT,    AND    EAR. 


Stricture   of   the   esophagus.      (Tracing    from    ai 
and    reduced. ) 

This  plate  was  taken  from  a  woman  forty  years  old.  At  the  age 
of  four  a  playmate  gave  In  r  a  drink  of  vitriol.  Since  then  she  has  always 
hail  to  chew  her  food  very  line.  For  a  month  or  two  before  she  came  for 
examination  she  had  b.-en  living  on  liquids. 

A  Xo.  I'u  F.  elastic  bougie  entered  the  stomach  with  difliculty,  encoun- 
tering a  stricture  at  the  cardiac  end  of  the  esophagus.  The  X-ray  (date 
shows  that  the  lower  half  of  the  esophagus  is  narrowed,  ruder  ether  a 
stricture  was  found  at  the  <  ml  of  the  clavicles  as  well  as  at  the  cardiac  end 
of  the  esophagus.  This  had  a  calibre  of  L'8  F.  The  upper  stricture  was 
dilated  first  with  the  mechanical  dilator  and  then  the  lower  one.  The  lower 
stricture  was  dilated  at  the  first  examination  from  L.'n  F.  to  '•'>-  F. 


LARYNCiOSCOPY,     BRONC I  lOSCOI'Y,    KSO1MI  AOOSCOI'Y,     K'IC.  '2.>( 

The  instrumentation  was  not  followed  by  any  rise  in  temperature,  but  for  a  few 
days  there  was  an  increase  of  the  epigastric  pain,  and  for  three  or  four  days  the 
ability  to  swallowr  was  lessened.  By  the  end  of  the  week  the  pain  had  disappeared  and 
the  patient  was  swallowing  better  than  before  the  operation.  At  this  time  a  number 
30  F.  elastic  bougie  passed  without  difficulty.  For  about  a  year  afterwards  bougies  wei" 
passed  on  the  average  of  every  two  weeks.  Today  a  number  36  F.  passes  without  diffi- 
culty and  the  woman  eats  every  thing. 

This  case  shows  that  where  there  are  two  or  more  constrictions  the 
bougie  locates  only  the  smaller  one.  From  the  age  of  the  lower  stricture 
and  from  its  firmness  at  the  beginning  of  the  dilatation  the  author  was 
of  the  opinion  that  it  would  have  to  be  cut  before  any  increase  of 
its  lumen  could  be  accomplished.  A  little  patience  in  the  use  of  the  me- 
chanical dilator,  however,  soon  proved  that  this  supposition,  however 
natural,  was  wrong'.  This  case  shows,  therefore,  the  possibilities  of 
rapid  dilatation  even  in  old  strictures.  It  shows  further,  that  the  bis- 
muth X-ray  examination  reveals  only  the  upper  stricture  and  gives  a 
false  impression  of  the  condition  of  the  esophagus  below  the  first  nar- 
rowing. 

Case   Number  3. 

Two  years  ago  a  boy  of  five  was  brought  to  the  Massachusetts  General  Hospital 
starving  from  the  effects  of  a  corrosive  stricture  of  the  esophagus.  His  stomach  was 
opened  under  cocain  anesthesia,  a  tube  inserted,  and  the  boy  brought  back  to  proper 
nourishment  and  resistance  by  stomach  feeding.  Then  attempts  were  made  to  pass 
the  stricture  from  above  by  introducing  bougies  and  by  having  the  boy  swallow  a  string 
to  act  as  a  guide  for  a  perforated  olive  on  a  metal  staff.  These  attempts  failed.  The 
attempt  also  failed  when  the  stricture  was  attacked  from  below  through  the  gastric 
fistula  by  means  of  a  cystoscope. 

A  year  later  the  boy  again  entered  the  hospital.  He  was  still  fed  through  a  tube 
in  the  gastric  fistula.  He  was  at  this  time  the  picture  of  health,  fat  and  pink.  The 
X-ray  revealed  a  constriction  of  the  esophagus  beginning  at  the  level  of  the  nipples  and 
continuing  on  to  the  stomach.  Above  the  stricture  the  esophagus  was  much  dilated. 
Examination  with  chemicals  proved  that  nothing  could  reach  the  stomach. 

Dr.  S.  J.  Mixter,  to  whose  wards  the  boy  was  admitted,  kindly  asked  the  author  to 
see  the  case.  The  examination  under  ether  showed  that  the  upper  half  of  the  esophagus 
was  dilated  and  that  the  stricture  began  as  the  X-ray  had  shown,  at  the  level  of  the 
nipples.  The  lumen  of  the  esophagus  was  reduced  to  a  central  opening  about  one-six- 
teenth of  an  inch  in  diameter.  A  filiform  bougie  would  just  engage  in  this  and  then 
would  enter  no  further.  Having  gained  this  information  from  above  an  attempt  was 
made  to  pass  the  stricture  from  below  through  the  gastric  fistula,  by  using  a  small 
short  bronchoscope.  This  was  not  successful.  Then  Dr.  Coolidge  took  the  broncho- 
scope  and  worked  from  below  while  the  author  worked  in  the  esophagus  from  above 
using  a  small  esophagoscope.  This  double  attack  on  the  stricture  made  no  gain  and  the 
manipulations  from  below  were  discontinued.  The  author  soon  found  that  on  using 
the  small  metal  olives  on  the  end  of  a  metal  staff  the  lumen  of  the  stricture  could  b'j 
entered  a  short  distance,  perhaps  an  eighth  of  an  inch.  Encouraged  by  this  he  persisted 
in  the  use  of  the  metal  olive,  using  first  the  metal  olive  and  then  a  small  elastic  bougie 
of  slightly  larger  size.  The  result  of  the  first  day's  work  was  the  ungluing  of  about 
an  inch  of  the  stricture.  No  reaction  followed  the  manipulations. 

Two  weeks  later  the  boy  was  etherized  again  and  the  same  manipulations  repeated 
A  second  gain  of  nearly  an  inch  was  secured.  During  this  second  session  at  the  stric- 


OPERATIVE    SURCEKY    OF    THE    XOSE,    THROAT,    AND    EAR. 

ture  the  ballooning  attachment  \vas  employed  from  time  to  time  in  order  to  clear  the 
blood  from  the  lumen  of  the  stricture  and  in  the  hope  that  some  of  the  air  might  find 
its  way  into  the  stomach.  Air  finally  did  enter  the  stomach  and  could  be  detected  com- 
ing out  of  the  gastric  fistula.  This  happening  was  most  comforting  and  encouraging. 
It  proved  that  the  metal  olive  was  following  the  right  line  and  that  the  lower  inch  of 
the  stricture  was  pervious  to  air.  Without  the  confidence  which  this  finding  gave  the 
author  might  have  given  up  the  attempt  to  pick  apart  so  long  a  stricture,  because  if  the 
line  of  the  stricture  was  not  adhered  to  closely  the  olive  would  perforate  the  walls  of 
the  esophagus  and  convert  the  case  into  a  tragedy.  After  a  second  interval  of  rest,  about 
two  weeks,  the  boy  was  etherized  for  the  third  time.  The  gain  made  at  the  other  exam- 
inations was  found  to  be  retained.  Air  still  could  be  forced  into  the  stomach,  and  after 
a  little  manipulation  the  olive  also  entered.  This  was  followed  by  soft  bougies  until 
the  lumen  of  the  stricture  was  increased  to  20  F.  The  mechanical  dilator  was  then 
put  in  and  expanded  at  intervals  to  28  F.  The  manipulations  ended  by  carrying  into 
the  stomach  a  thread  and  bringing  the  upper  end  of  this  out  of  the  mouth  and  fixing 
it  over  the  ear. 

Three  or  four  days  later  the  perforated  metal  olive  on  a  long  staff  was  carried 
down  on  the  thread  into  the  stomach.  The  boy  began  to  drink  milk.  It  was  soon  pos- 
sible to  pass  the  olive  through  the  stricture  without  using  the  string  as  a  guide.  This 
was  fortunate  because  the  thread  was  vomited  after  a  few  days.  The  further  treat- 
ment of  the  case  consisted  in  passing  larger  and  larger  olives  at  appropriate  intervals 
until  a  final  dilatation  of  36  F.  was  reached. 

In  this  ease  an  absolute  stricture  three  inches  long1  and  a  year  old 
was  opened  up  piecemeal  with  a  final  lumen  of  3(>  F.  The  previous 
treatment  of  the  case  along'  general  surgical  lines  had  failed.  This 
fortunate  case,  therefore,  shows  in  a  striking  manner  the  possibilities 
of  the  treatment  of  strictures  by  the  esophagoscope  and  by  appropriate 
instruments  used  through  it. 

The  Use  of  a  Thread  as  a  Guide  in  Esophageal  Strictures. — The 
procedure  of  having  the  patient  swallow  a  thread  was  a  great  advance 
in  the  general  surgical  treatment  of  strictures  of  the  esophagus.  It  is 
mentioned  in  connection  with  the  use  of  the  esophagoscope  because 
occasionally  advantage  may  be  taken  of  this  procedure  in  connection 
with  the  use  of  the  tube.  The  swallowed  thread  may  be  used  to  guide 
the  esophagoscope  to  the  lumen  of  the  stricture,  although  as  the  oper- 
ator becomes  accustomed  to  the  use  of  the  esophagoscope  and  resorts 
to  ballooning,  he  will  find  the  swallowed  thread  less  and  less  necessary. 
The  chief  use  of  the  thread  is  its  employment  as  a  guide  for  the  metal 
olive  alter  the  rapid  dilatation.  When  used  in  this  way  a  yard  or  two 
of  stout  waxed  thread  is  wrapped  about  a  small  button  and  the  button 
is  carried  into  the  stomach  through  the  tube  during  the  examination 
and  after  the  stretching.  The  upper  end  of  the  thread  is  brought  out 
of  the  mouth  and  fastened  over  the  ear.  (Jenerally  the  use  of  the  thread 
as  a  guide  for  the  metal  olive  and  its  staff  is  necessary  for  a  few  days 
only,  because  the  operator  soon  becomes  orientated  in  regard  to  the 

•n  of  the  stricture  and  finds  that  the  metal  staff  allows  him  to  turn 


LARYNGOSCOPY,    BRONCHOSCOPY,    KSOI'II  AGOSCOl'Y,     KTC.  '2WJ 

the  olive  in  different  directions  and  to  probe  for  the  opening  of  the  stric- 
ture successfully. 

The  Spiral  Staff  for  Carrying  Olives.— The  purpose  of  introducing 
the  metal  olive  and  its  staff  is  that  olives  of  increasing  size  may  be 
passed  on  the  metal  shaft  until  the  dilatation  of  the  stricture  is  such  that 
the  passage  of  elastic  bougies  is  possible.  (Fig.  18.'}.)  Instead  of  forcing 
the  perforated  olive  down  the  staff  and  through  the  stricture  by  a  second 
staff  carrying  a  ring  placed  at  right  angles  to  the  shaft,  better  results 


Fig.  181. 
Handle   and   staff'   of   Plummer's   esophageal    whalebone   bougie. 


Fig.  182. 

Whalebone  staff  of  Plummer's  esophageal  bougie  fitted  with  two  olives. 
The  first  olive  is  pierced  to  run  on  a  thread.  The  olives  are  made  in 
graduated  sizes. 


Fig.  183. 

A,  Metal  staff  carrying  a  perforated  olive  at  the  tip  (Mixter)  :  B.  Special 
wire  carrier  (Mosher),  on  which  various  sizes  of  olives  are  screwed;  C, 
Graduated  olives. 

can  be  obtained  by  employing  the  spiral  wire  carrier.  The  ilexible 
pusher  buckles  away  from  the  line  of  the  main  staff,  and  so  at  times 
refuses  to  push  a  snug  olive  through  the  stricture.  The  spiral  wire  car- 
rier, on  the  other  hand,  hugs  the  guiding  staff  closely  and  gives  a  direct 
push  on  the  olive.  "\Vhen  the  olive  is  in  position  against  the  stricture  if 
the  operator  puts  his  finger  in  the  patient's  pharynx  and  presses  down- 
ward on  the  spiral  staff,  he  can  exert  great  pressure  on  the  olive  below. 
In  fact  the  author  found  that  this  method  of  forcing  an  olive  through  >f\ 


•J40 


OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT.    AND    EAR. 


stricture  was  so  powerful  that  care  was  necessary  or  the  stretching  of 
the  stricture  would  be  too  rapid  and  followed  by  a  reaction.  A  series 
of  olives  of  increasing  sizes  comes  with  the  spiral  staff.  An  olive  of 
any  size  can  be  extemporized.  In  the  case  of  the  boy  (Case  -'!,  page  -37) 
an  olive  of  the  desired  size  not  being  at  hand  an  olive  was  wound  on 
the  staff  by  using  coarse  surgical  silk.  The  silk  was  given  a  smooth 
coating  by  smearing  it  with  modelling  compound  such  as  dentists  use 
for  taking  impressions  of  the  teeth.  The  spiral  staff  permits  two  or 
more  olives  of  increasing  size  to  be  put  on  at  once.  These  may  be  placed 
at  intervals  after  the  fashion  of  Bunt's  bougie.  (Fig.  175).) 

The  After  Care  of  Stricture  of  the  Esophagus. — When  a  stricture  of 
the  esophagus  has  been  dilated  sufficiently  to  permit  the  patient  to 
swallow  readily,  bougies  of  maximum  size  must  be  passed  at  intervals 
of  a  week  or  two  or  monthly,  for  months  or  years.  Not  infrequently 
adult  patients  learn  to  pass  the  bougie  upon  themselves. 


Fig.  184. 
Mother's  two-bladed  dilator  with  sliding  knife  for  cutting  strictures  of    the  esophagus. 

Spastic  Stenosis  of  the  Esophagus. 

Esophagospasm  (Esophagismus). — Esophagospasm  is  an  exces- 
sive irritability  of  the  esophagus.  It  prevents  the  introduction  of  the 
esophagoscope  under  local  anesthesia.  I  ndcr  general  anesthesia,  how- 
ever, the  esophagoscope  passes  easily.  On  examination  the  esophagus 
is  found  to  be  normal,  or  if  any  lesion  is  discovered  it  is  almost  always 
a  simple  nlceration.  Ksophagospasni  is  the  underlying  condition  in 
globns  hystericiis.  It  should  be  remembered  thai  a  diagnosis  of  globus 
liystericus  is  made  less  and  less  often  since  the  use  of  the  esophago- 
scope has  become  common.  ()n  this  account  the  diagnosis  should 
always  be  looked  upon  \vith  suspicion. 

The  treatment  of  esophagospasm  is  to  pass  t  he  esophagoscope  under 
ether  anesthesia  and  to  treat  any  nlceration  present  with  some  mild 
caustic.  If  the  esopliageal  wall  proves  to  be  normal  the  regular  pass- 
ing of  elastic  bougies  in  time  establishes  tolerance  and  does  away  with 
the  sensitiveness  of  the  esophagus. 


LAKYXfiOSCOPY,     BROXCHOSCOPV,     KSOIM  I  A<  i<  )Sl  '<>\'\  ,     K  K   . 


L'41 


Cardiospasm. — Cardiospasm  is  the  name  applied  to  a  condition  of 
spasmodic  closure  of  the  esophagus  at  the  cardiac  opening  of  the  stom- 
ach. The  name,  however,  is  used  in  connection  with  spasmodic  closure  of 
the  esophagus  at  any  other  point.  This  condition  is  one  of  the  most  im- 
portant pathologic  affections  of  the  esophagus.  Its  etiology  is  still  ob- 
scure. .Jackson  holds  that  the  cardia  is  not  a  true  sphincter  in  spite  of 


Fig.  185. 

Cardiospasm.  Retouched  tracing  from  an  X-ray  plate.  The  esophagus 
is  filled  with  bismuth  gruel,  and  is  narrowed  to  a  very  small  lumen.  Above 
the  narrowing  it  is  dilated.  (Author's  case.) 

the  circular  libers  of  Hyrtl,  but  maintains  that  the  hiatus  is  an  actual 
sphincter  and  acts  as  one.  In  Cardiospasm  there  are  two  chief  features, 
spasm  of  the  cardia  and  dilatation  of  the  esophagus.  In  the  majority  of 
the  cases  there  is  atony  of  the  muscular  wall  as  well.  The  conditions 
which  are  responsible  for  these  changes  have  been  held  by  various 
writers  to  be  a  congenital  defect,  a  primary  neurosis,  or  an  esophagitis. 
In  some  cases  the  atony  is  primary  to  the  spasm  and  dilatation,  in  oth- 


242  OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

ers  the  spasm  comes  first.  Lerche  maintains  that  an  attempt  should  be 
made  from  the  clinical  histories  to  divide  cases  into  the  two  classes  just 
mentioned.  Gottstein  gives  the  following  classification:  (A)  Cases  in 
which  excessive  spastic  nmsenlar  contractions  take  place.  (B)  Cases 
in  which  the  contractility  of  the  muscles  is  weakened  or  lost.  (1) 
Cases  are  classed  as  idiopathic  in  which  no  organic  lesion  can  be  dem- 
onstrated, (2)  as  secondary  or  symptomatic  when  due  to  some  anatom- 
ic alteration  as  ulcer  or  cancer. 

Under  class  A  (excessive  muscular  contraction)  are  grouped:  eso- 
phagospasm,  and  cardiospasm.  The  first  involves  the  esophagus 
proper  and  the  second  only  the  cardia.  Cardiospasm  may  be  acute  or 
chronic. 

Leichten stern  defines  cardiospasm  as  a  pathologic  exaggeration  of 
a  physiologic  phenomenon,  due  to  abnormal  innervation  of  the  cardia. 
It  produces  an  habitual,  non-permanent,  spastic  closure  of  the  cardia. 
This  is  greater  than  normal,  lasts  a  long  time,  and  occurs  especially 
after  meals.  It  is  not  known  whether  the  condition  is  caused  by  a  fail- 
ure of  the  inhibitory  nerve  fibers  which  control  the  normal  tonns  of 
the  cardia  or  to  some  irritation  which  causes  an  increased  tonus  in  the 
contracting  fibers. 

FREQUENCY  OF  CARDIOSPASM. — Both  sexes  are  affected  equally.  The 
majority  of  the  cases  occur  between  the  ages  of  twenty  and  forty,  but 
cases  have  been  reported  in  which  the  patients  were  eight  and  four 
years  old.  The  latter  case  was  one  of  acute  cardiospasm. 

ANATOMIC  CONSIDERATIONS.- — According  to  Kumpel  the  capacity  of 
the  esophagus  varies  between  40  cc.  and  SO  cc.  but  even  150  cc.  may  be 
considered  within  physiologic  limits.  The  position  of  the  cardia 
changes  with  age.  In  the  infant  it  is  found  at  the  level  of  the  eighth 
dorsal  vertebra  whereas  in  the  aged  it  may  be  placed  as  lo\v  as  the 
twelfth  dorsal  vertebra.  In  the  neck  the  esophagus  is  closed,  but  in 
the  chest  it  is  open  and  contains  air.  Mikulicz  found  that  the  intraeso- 
phageal  pressure  during  rest  was  a  little  below  that  of  the  atmosphere. 
By  (|iiiet  inspiration  the  pressure  is  lowered  to  !)  cm.  water  pressure 
ami  by  forced  inspiration  to  20  cm.  or  below.  ()n  quid  expiration  the 
pressure  rises  to  10  cm.  water  pressure,  and  by  forced  expiration  to 
20  cm.  Coughing  may  raise  the  pressure  to  (iO,  SO,  or  even  1(50  mm. 
mercury.  On  swallowing  the  pressure  varies  between  O.SO  mid  22  cm. 
water.  The  normal  esophagus  opens  easily  without  the  aid  of  swal- 
lowing for  the  passage  of  fluids  and  gases  from  the  esophagus  into  the 
stomach,  but  opens  with  difficulty  for  their  passage  in  the  reverse  di- 
rection. The  pressure  necessary  to  open  the  cardia  amounts  to  a  frac- 
tion of  the  pressure  of  a  column  of  water  filling  the  thoracic  portion 


LAKYNtJOSCOl'V,     BRONCHOSCOPY,     KSOIMI  A<  iosrol'Y.     KTr. 


24:} 


of  the  esophagus.  When  irritating  fluids  such  as  very  hot  or  cold 
liquids  or  carbonized  drinks  are  taken  the  pressure  necessary  to  force 
them  down  is  higher. 

If  the  resistance  of  the  eardia  is  increased,  a  part  of  the  fluid  swal- 
lowed will  remain  in  the  esoph- 
agus. Suppose  that  in  order  to 
effect  automatic  opening  of  the 
eardia  under  normal  conditions 
a  pressure  of  12  cm.  water  pres- 
sure is  necessary.  In  this  case 
the  excess  of  fluid  over  12  em. 
would  flow  into  the  stomach  by 
its  weight,  leaving  behind  a  12 
cm.  column  of  fluid.  The  next  act 
of  swallowing  which  corresponds 
to  about  12  cm.  water  pressure 
would  carry  this  into  the  stom- 
ach. If  the  resistance  of  the  ear- 
dia corresponds  to  24  cm.  water 
pressure,  there  will  be  left  a  col- 
umn of  12  cm.  at  the  end  of  the 
act  of  swallowing.  If  the  resist- 
ance of  the  eardia  is  still  higher 
only  so  much  fluid  will  pass  the 
eardia  as  is  pressed  down  by  the 
muscles  of  the  pharynx.  The  eso- 
phagus itself  can  overcome  the 
resistance  of  the  eardia  only  by 
energetic  contraction.  In  a  nor- 
mal esophagus  the  effect  of  this 
increased  pressure  on  the  eso- 
phagus is  small  but  as  soon  as  the 
esophagus  becomes  dilated  the 
effect  of  the  increased  pressure 
which  is  necessary  to  force  food 
through  the  unyielding  eardia  is 
to  make  the  esophagus  dilate 
more  and  more.  Stagnating  food 
leads  to  changes  in  the  esopliageal  wall  which  further  weaken  it. 

Mikulicz  used  the  esopliageal  pressure  during  swallowing  as  an 
indication  of  the  contractile  power  of  the  esophageal  muscles.  He 
therefore  measures  this  pressure.  Lerche  has  devised  an  apparatus 
for  doing  this.  (Fig.  186.) 


Apparatus      for 
(After   Lerche.) 


Fig.   186. 
dilating 


tin 


eardia. 


244  OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

THE  SYMPTOMS  OF  CARDIOSPASM. — The  two  chief  .symptoms  of  cardi- 
spasm  are  difficulty  in  getting  food  into  the  stomach,  and  frequent 
regurgitation.  Often  the  patient  lias  a  troublesome  cough  at  night,  or 
is  awakened  by  food  running  back  into  the  pharynx  and  into  the  nose. 
If  the  condition  has  existed  for  some  time  the  patient  is  much  ema- 
ciated. 

EXAMINATION. — The  history  of  the  patient  should  exclude  syphilis, 
and  the  swallowing  of  caustics  or  foreign  bodies.  In  the  general  phys- 
ical examination  of  the  pressure  from  an  aneurism,  a  goitre,  or  a  tumor 
in  the  mediastinum  should  be  constantly  borne  in  mind.  The  esopha- 
geal  examination  should  be  ruled  out  in  the  presence  of  ulcers,  and  of 
malignant  or  benign  growths.  It  must  be  remembered  that  a  large 
or  a  low  seated  diverticulum  of  the  esophagus  may  be  present. 

Much  light  is  often  thrown  on  a  case  by  filling  the  esophagus  with 
bismuth  and  then  taking  an  X-ray  plate. 

The  Examination  ruder  Local  Anestl/esia. — A  large  sized  elastic 
bougie  is  introduced  into  the  esophagus  and  the  distance  of  the  ob- 
struction from  the  incisor  teeth  is  found.  In  a  case  of  cardiospasm  the 
bougie  will  occasionally  pass  through  the  cardia  easily  or  on  gentle 
pressure,  at  other  times  much  pressure  is  needed  to  force  it  through. 
The  esophagus  is  washed  out  and  the  throat  cocainized.  Then  the  eso- 
phagoscope  is  passed  and  a  careful  examination  is  made  of  the  esopha- 
gus. The  condition  of  the  mucosa  and  of  the  esophageal  walls  is  noted. 
It  should  be  ascertained  whether  the  walls  are  firm  or  flaccid  and 
whether  the  esophagus  is  normal  iu  size  or  dilated.  I'lcerations,  diver- 
ticulum and  new  growths  are  excluded.  When  the  tube  reaches  a  proper 
depth  the  cardia  is  seen  as  a  slit  with  the  long  diameter  lying  obliquely 
from  the  right  posteriorly  to  the  left  anteriorly.  This  is  not  the  cardia 
strictly  speaking  but  the  hiatus  of  the  esophagus,  though  many  writers 
use  this  name  for  the  constriction  of  the  esophagus  at  the  point  where 
it  goes  through  the  diaphragm.  The  hiatus  appears  either  as  a  slit 
or  as  a  rosette.  In  spasm  it  is  usually  like  a  rosette.  It  has  been  com- 
pared to  the  mouth  of  the  cervix  uteri.  (  Fig.  His.)  The  esophagoscope 
cannol  be  passed  in  cases  of  cardiospasm  inlo  the  stomach  without 
first  cocainizing  the  hiatus.  As  soon  as  the  hiatus  gives  way  the  tube 
is  carried  into  the  stomach  and  then  withdrawn.  On  the  withdrawal 
the  esophagus  is  examined  again  in  order  to  confirm  the  negative  find- 
ings. 

In  a  complete  examination  the  next  step  is  to  determine  the 
capacity  of  the  esophagus.  An  esopliagometer  is  used  for  this  purpose 
Lcrche  has  devised  an  instrument  of  this  nature,  ll  consists  of  a  rub- 
ber bag  which  is  inserted  into  the  esophagus  and  then  filled  with  air. 
A  recording  mechanism  registers  the  amount  of  air  necessary  to  make 


LARYNCOSCOI'Y,     BliOXCllOSroi'Y,     KS( )  I '  1 1  A< ;( )S( '( )l  '\ ',     KTC.  '-'45 

the  bag  assume  the  same  dilatation  and  shape  as  the  esophagus.  An 
X-ray  picture  may  he  taken  with  the  I  mi;1  in  place.  This  will  demon- 
strate the  shape  of  the  dilation  more  sharply  than  the  bismuth  gruel. 

Tin-:  TRKAT.MKXT  ()!•'  ( 'A  HDiosi'ASM . — The  treatment  of  cardiospasm 
consists  in  stretching  the  hiatus  of  the  esophagus.  This  can  be  ef- 
fected with  a  pliable  dilator  like  a  rubber  bag,  or  with  an  instrument 
modelled  on  the  principle  of  the  urethral  dilator.  The  rubber  bags 
are  generally  used  under  local  anesthesia.  The  apparatus  used  by 
Lerelte  is  shown  in  Fig.  186'.  It  consists  of  a  stomach  tube  the  end  of 
which  is  covered  with  a  sausage-shaped  silk  bag  K )-!'_'  cm.  lon.u1.  The 
bag  is  distended  by  connecting  the  apparatus  with  a  water  faucet. 
A  secondary  mechanism  regulates  the  amount  and  the  pressure  of 
the  water  and  so  the  pressure  exerted  by  the  bag  when  it  is  in  place. 

The  use  of  bougies  in  pronounced  cases  of  cardiospasm  for  dilating 
the  hiatus  does  not  give  good  results. 

(lUinprecht  has  stated  that  the  maximum  dilatation  to  which  the 
normal  cardia  can  be  stretched  is  respectively  .'>  cm.  and  .'!..")  cm.  Schciber 
found  that  the  normal  cardia  from  the  stomach  side  could  withstand 
a  pressure  of  .'550  grams  for  a  few  seconds.  Strauss  distended  the 
rubber  bag  with  air  and  had  his  apparatus  so  regulated  that  a  pres- 
sure of  not  more  than  L'5()  cm.  of  mercury  could  be  brought  upon  the 
cardia.  Jacobs  using  a  mechanical  dilator  fashioned  on  the  plan  of 
the  urethral  dilator  stretched  the  cardia  to  a  diameter  of  IJ.o  cm. 
Alikulic/  working  from  within  the  stomach  stretched  the  cardia  to 
a  diameter  of  7  cm. 

Tin-  Trrtif n/rnf  <>!  Cardiospasm  Cmlrr  Ether. -  -  An  examination 
under  ether  is  much  easier  for  the  patient.  The  stretching  of  the 
cardia  with  the  mechanical  dilator  is  much  simpler  than  the  use  of  the 
rubber  bags.  There  is  one  drawback,  however,  to  the  examination 
under  ether.  All  spasm  of  the  esophagus  is  done  away  with  and  the 
cardia  itself  may  so  be  relaxed  that  unless  the  examiner  bears  this  fact 
in  mind  he  may  feel  that  ho  has  not  found  the  cause  of  the  condition  for 
which  the  examination  is  undertaken.  After  the  ether  examination  in 
cases  of  cardiospasm  and  the  dilatation  of  the  cardia  the  author  has 
been  in  the  habit  of  leaving  a  thread  in  the  esophagus  and  in  the  stom- 
ach and  of  passing  the  olive  tipped  staff  on  the  thread  for  a  few  days 
until  it  was  possible  to  pass  the  staff  unguided.  ( )n  the  staff  metal 
olives  of  increasing  size  are  passed  for  a  time  and  then  the  unguided 
elastic  bougie.  Finally  the  patient  is  taught  to  pass  the  bougie  for  him- 
self. This  he  does  at  intervals  according  to  the  persistence  of  the 
spasm. 

The  relief  of  cardiospasm  is  easily  brought  about.  The  patient's 
symptoms  lessen  almost  immediately.  Measurements  show  that  the 


246 


OPEKATIVE    SUR<;EKY    OF    THE    NOSE,    THROAT,    AXD    EAR. 


esophagus  soon  contracts  unless  there  has  been  extensive  weakening 
of  the  esophageal  walls.  Cases  of  this  kind  although  they  obtain 
marked  relief  from  stretching  of  the  cardia  naturally  still  have  a 
certain  amount  of  residual  trouble  on  account  of  the  slowness  with 
which  food  passes  the  weakened  esophagus.  Cases  of  cardiospasm 


('anliospiisni.      From    a    print    of   an    X-ray    plate,    showing   a    dilated    eso- 
phagus.    The  esophagus  narrows  to  a  point   in  the  shadow  of  the  diaphragm. 
(  Plate   by    Dr.    F.    11.    Williams.) 


LARYNtiOSCOPY,    BRONCI I  OSCOI'Y,     KSOI'I  I  A<iOSCOPY,     KTC.  247 

are  among  the  most  dramatic  of  surgery.  The  following  case  is  an 
example:  A  young  woman  had  been  regurgitating  her  food  for  fifteen 
years.  She  went  from  physician  to  physician.  She  was  constantly 
eating  but  was  always  hungry,  and  consumed  enough  food  for  two  or 
three  people  but  continually  wasted  away.  When  she  laid  down  food 
regurgitated  into  her  mouth  or  her  nose.  This  and  a  constant  cough 
kept  her  awake.  In  a  short  ether  examination  lasting  about  the  same 
number  of  minutes  as  she  had  been  ill  years  the  cause  of  the  trouble 
was  discovered  and  practically  cured.  (Fig.  187.) 

Phrenospasm. — Phrenospasm  is  the  name  applied  by  Jackson  to 
spasmodic  closure  of  the  esophagus  at  the  hiatus.  This  condition  is 
frequently  seen  in  passing  the  esophagoscope  without  anesthesia. 
Frequently  the  esophagoscope  is  hugged  so  tightly  that  the  subphrenic 
portion  of  the  esophagus  cannot  be  entered,  ruder  general  anesthesia 
the  spasmodic  closure  of  the  hiatus  disappears.  This  characteristic 
disappearance  of  the  spasm  together  with  a  normal  mucosa  establishes 
the  diagnosis  of  phrenospasm.  Almost  invariably  the  esophagus  is 
dilated  above  the  hiatus. 

Jackson  makes  a  clear  distinction  between  spasm  of  the  cardia 
and  spasm  of  the  hiatus.  Many  authors  do  not,  but  speak  of  spasm 
of  the  cardia  when  in  reality  they  mean  spasm  of  the  hiatus.  Then 
again  the  term  spasm  of  the  cardia  is  used  to  mean  spasm  either  at 
the  cardia  or  at  the  hiatus.  Jackson's  terminology  leads  to  clearness. 

Benign  New  Growths  of  the  Esophagus. 

Benign  neoplasms  of  the  esophagus  occur  but  are  not  common. 
When  it  becomes  the  routine  to  examine  all  cases  of  slight  trouble 
with  swallowing  in  all  probability  more  benign  new  growths  will  be 
discovered.  Edematous  polyps  and  pedunculated  lipomata  are  prob- 
ably the  commonest  of  the  benign  growths.  Fibromata  also  occur. 

These  benign  growths  are  found  chiefly  in  the  upper  part  of  the 
esophagus.  Their  pedicles  allow  them  to  play  up  and  down  so  that 
they  appear  at  one  examination  and  may  disappear  at  the  next  or 
they  are  present  when  the  examiner  first  looks  into  the  throat  with 
the  7iiirror  and  they  disappear  when  the  patient  swallows.  Peduncu- 
lated lipomata  have  a  fashion  of  dropping  forward  into  the  larynx 
and  of  causing  cough  and  intermittant  hoarseness. 

Treatment  of  Benign  New  Growths. — Benign  new  growths  should 
be  removed  with  appropriate  grasping  or  cutting  forceps.  An  effort 
should  be  made  to  obtain  as  much  of  the  pedicle  and  its  base  as  is 
possible.  Sometimes  the  manipulations  can  be  carried  out  through 
the  tubular  speculum,  whereas  at  other  times  the  esophagoscope  is 


OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 


necessary.  The  accessibility  of  the  growth  and  the  tolerance  of  the 
patient  settle  the  question  of  the  use  of  local  or  general  anesthesia. 
With  the  exception  of  lipomata  all  supposedly  benign  growths  are 
looked  upon  with  a  certain  amount  of  suspicion.  In  any  given  case 
time  alone  can  settle  whether  or  not  this  suspicion  is  well  founded. 

Malignant  New  Growths  of  the  Esophagus. 

Any  persistent  difficulty  of  swallowing  in  a  patient  of  the  cancer 
age  ought  to  lead  to  a  prompt  examination  of  the  esophagus.  Only  in 
this  way  can  malignant  disease  be  detected  early  and  the  cases  which 
are  n't  for  operation  sorted  out.  Cancer  of  the  esophagus  often  gives 


Fig.  188. 
Section    of   normal    esophagus    (Low   power). 

but  .-li.u'ht  symptoms  for  a  number  of  years.  It  is  not  uncommon  to 
have  patients  give  a  history  of  trouble  with  swallowing  dating  back 
three  or  four  years.  The  horrors  of  cancel'  are  nowhere  greater 
than  in  cancer  of  the  esophagus.  If  for  no  other  reason,  therefore, 
these  patients  should  be  given  the  benefit  of  an  early  examination  and 
of  an  early  diagnosis. 

Malignant  disease  may  start  in  the  epithelium  of  the  esophagus, 
or  in  its  muscular  wall,  or  outside  of  it.  In  late  cases  no  conclusion  can 
be  arrived  at  a>  to  origin  of  the  disease. 

Periesophageal  disease  when  not  far  advanced  appears  through 
the  esophagoscopc  as  a  hard  nodule  projecting  into  the  lumen  of  the 
esophagus  and  over  which  the  mucous  membrane  is  normal. 


LARYXOOSCOI'Y,     IWOXC  1 1  OS< 'Ol'Y  ,     KS< »!'  1 1  A<  :<  )S(  '< )  l">  ,     I-/I  <   .  1_'4!> 

Gottstein,  quoted  by  .Jackson,  describes  the  appearance  of  can- 
cer  of  the  esophagus  under  live  heads. 

1.  The  esophageal  wall  shows  thickened  whitish  patches.  These 
white  patches  alternate  with  patches  of  bright  red. 

'2.  There  is  a  ring-like  narrowing  of  the  lumen  of  the  esophagus. 
This  is  called  the  annular  form.  At  some  point  in  the  rimr  there  is 
usually  ulceration.  FYequently  the  esophagus  is  dilated  above  the 
constriction. 

'.).  Carcinomatous  infiltration  which  is  not  only  aiinnlar  in  form 
but  funnel-shaped. 

4.  Cauliflower  masses  surrounding1  the  lumen  of  the  esophagus. 

5.  Papillomatous   vegetations. 


In  the  author's  experience  the  most  common  forms  are  the  first, 
second  and  the  fourth.  Syphilis  may  simulate  any  of  the  five  forms. 
The  microscopic  examination  of  a  specimen  combined  with  the  thera- 
peutic and  the  Wassermann  test  will  rule  out  syphilis. 

Cancer  of  the  esophagus  occurs  oftenest  at  the  upper  or  the  lower 
end.  It  is  not  uncommon,  however,  to  find  it  located  about  half  way 
down  the  esophagus. 

Symptoms  of  Cancer  of  the  Esophagus. — The  chief  symptom  of  can- 
cer of  the  esophagus  is  difficulty  in  swallowing.  This  symptom  may 
be  slight  for  years.  Associated  with  the  difficulty  in  swallowing,  if 
the  growth  is  located  in  the  upper  part  of  the  esophagus,  there  is 
pain  radiating  to  the  ear  of  the  affected  side.  Often  the  cervical  glands 
are  enlarged.  They  become  infected  even  if  the  cancel1  is  situated  at  tin- 
cardiac  end  of  the  esophagus.  Later  in  the  disease  when  the  ingestion 
of  food  is  impeded,  emaciation  sets  in. 

Diagnosis  of  Cancer  of  the  Esophagus.— The  old  method  of  making 
a  diagnosis  of  cancer  of  the  esophagus  was  to  label  the  difficulty  in 
swallowing  by  some  such  name  as  globus  liystericus, or  neurasthenia, 
and  to  temporize  until  obstruction  became  marked  and  emaciation 
noticeable.  Then  a  bougie  was  passed,  an  obstruction  was  found  and 
the  bougie  brought  up  blood.  Today  this  is  antiquated  surgery,  to 
call  it  by  no  harder  name.  The  bougie  has  cost  many  a  patient  his 
life  not  only  by  delaying  the  diagnosis  until  too  late  but  also  by  per- 
forating the  weakened  walls  of  the  cancerous  esophagus. 

Diagnosis  and  Treatment  of  Cancer  of  the  Esophagus. — Cancer  of 
the  esophagus  is  best  diagnosed  by  the  esophagoscope  or  by  the  open 
or  tubular  speculum.  Palliative  treatment  is  also  best  carried  out 
through  these  instruments.  The  removal  of  a  specimen  for  microscopic 
examination  may  seem  a  trivial  affair  in  such  an  ugly  disease,  but 
the  surgical  satisfaction  which  comes  from  it  is  not  to  be  despised. 


OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

If  the  cancer  is  well  advanced  and  happens  to  be  in  the  upper  part  of 
the  esophagus  the  tubular  speculum  gives  a  splendid  view  and  enables 
the  surgeon  to  remove  a  generous  specimen  quickly  and  easily.  Good 
biting  forceps  are  necessary  for  this  procedure,  and  care  must  be 


Carcinoma    of    the;    esophagus. 


taken  to  pierce  \vell  into  the  tumor.  (Fig.  ISO.)  It'  the  mucous  mem- 
brane over  the  suspected  area  is  unbroken  it  may  be  questioned  whether 
or  not  it  is  justifiable  to  cut  into  it.  I'nless  this  is  done,  however,  the 


LAHYN<;OS('OPY,    BRONCHOSCOPY,    KSOPH  AOOSCOPY,     K'l  (  .  L'51 

case  must  bo  left  in  doubt.  If  the  examination  is  carried  out  under 
ether  and  the  growth  is  situated  at  or  near  the  mouth  of  the  esophagus, 
the  open  speculum,  given  a  favorable  nock,  affords  a  good  view  and 
enables  the  operator  not  only  to  remove  a  specimen  but  to  clear  away 
a  great  part  of  the  fnngating  growth.  In  cancel1  below  the  mouth  of  the 
esophagus,  if  it  is  of  the  cauliflower  typo,  careful  curetting  will  remove 


Fig.  190. 
Section   of  carcinomatous  area    (Low   power).      (See   Fig".   189.1 

the  obstructing  masses  and  restore  the  patient's  ability  to  swallow  soft 
food.  The  author  believes  from  his  results  that  this  procedure  is  justi- 
fiable. The  curetting  may  be  repeated  two  or  three  times.  (Figs.  190 
and  191.)  The  examination  of  a  case  of  cancer  of  the  esophagus  is  not 
ideally  complete  unless  the  lumen  of  the  cancerous  stricture  is  ascer- 
tained and  the  presence  of  a  secondary  growth  lower  down  is  deter- 
mined. (Figs.  192  and  1911)  In  order  to  accomplish  this  a  smaller 


252 


OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 


Fig.   191. 
Section  of  earcinomatous  area   (High  power).     (See  Fig.  190.) 


Fig.   19L>. 

Can-iiiomatoiis   stricture    of   the    esophagus. 
(  Plate    by    [)r.    \V.    .7.    Dodd.) 


LAHYNOOSCOI'Y,     BHOXC  1 1  OS( 'OI'Y,     KS(  )|'l  I  A<  ',( )S(  '<  >\>\  , 


tube  should  be  passed  through  the  larger  esophagoseopc  ;in<l  carried 
down  through  the  rest  of  the  esophagus.  It  is  not  always  possible  to  do 
this;  nevertheless  the  attempt  should  be  made. 


Fig.  193. 

Cancer  of  the  esophagus.  Retouched  tracing  from  X-ray  plate.  (Lateral 
view.)  The  esophagus  is  tilled  with  bismuth  gruel.  At  the  point  where 
the  growth  is  the  esophagus  ends  in  an  irregular  cone.  Splashes  of  bis- 
muth which  have  passed  through  the  stricture  are  seen  below.  (Author's 
case.) 


When  the  walls  of  the  esophagus  are  surrounded  with  fungating 
masses  of  cancerous  growth  it  is  hard  to  tell  where  the  lumen  of  t he- 
esophagus  is  placed.  In  such  a  case  if  the  esophagus  is  ballooned 


254  OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 

with  air  the  displacement  of  the  cancerous  masses  reveals  the  site 
of  the  esophageal  opening.  If  no  opening  is  found  but  the  air  enters 
the  stomach,  pressure  on  the  abdomen  will  force  the  air  back  and  as 
it  bubbles  upwards  through  the  structure  the  lumen  can  be  located. 
In  extensive  disease  of  the  esophagus  the  esophageal  lumen  can  be 
saved  for  a  time  by  intubing  the  carcinomatous  stricture  with  a  small 
clastic  webbing  funnel  after  the  method  of  Mixter. 

It  is  justifiable  to  dilate  a  cancerous  stricture  with  bougies  or 
with  the  mechanical  dilator  only  by  using  these  instruments  through 
the  esophagoscope  and  under  visual  guidance.  Even  with  these  safe- 
guards the  procedure  must  be  employed  with  extreme  care. 

What  every  physician  hopes  to  find  in  a  case  of  cancer  is  that  the 
new  growth  is  located  at  the  upper  part  of  the  esophagus,  that  it  is 
not  extensive  and  that  it  is  of  a  low  grade  of  malignancy.  Such  cases 
offer  a  chance  of  cure  if  the  larynx  is  removed  and  the  diseased  por- 
tion of  the  esophagus  resected.  Patients  who  might  have  been  saved 
by  this  method  have  gone  to  their  graves  without  any  attempt  having 
been  made  to  relieve  them.  Such  cases  exist  today,  but  they  will  never 
be  found  except  by  the  routine  use  of  the  esophagoscope.  When  hope- 
less cases  are  encountered,  and  they  are  still  in  the  great  majority,  an 
early  opening  of  the  stomach  will  save  the  patient  from  starving  to 
death.  The  author  cannot  understand  the  reluctance  of  some  surgeons 
to  giving  the  patient  the  benefit  of  this  operation. 

Compression  Stenosis  of  the  Esophagus. 

Structures  which  border  on  the  esophagus  may  push  upon  it  and 
cause  compression.  The  conditions  which  are  commonly  found  to 
do  this  are  glandular  enlargements,  cervical  or  inediastinal  tumors, 
aneurism,  plural  effusions  and  spinal  deformities. 

The  esophageal  examination  in  these  cases  shows  only  a  nar- 
rowed lumen.  The  general  physical  examination  supplemented  by  an 
X-ray  plate  are  the  most  efficient  means  of  arriving  at  a  correct 
diagnosis  of  the  cause  of  the  compression.  In  an  aneurism  the  pulsa- 
tions may  be  seen  through  the  fluoroscope. 

DISKASKS  OK  T11M    KS(  )PI  I  A(  JCS   WHICH    DO   NOT  CAl'SK 

STENOSIS. 

Inflammation  and  Ulceration  of  the  Esophagus. 

In  acute  inflammation  of  the  esophagus  the  usual  signs  shown  by 
an  inflamed  mucous  membrane  are  present.  According  as  the  inflamma- 
tion is  general  or  local  there  is  a  small  or  an  extensive  area  of  redden- 
in  ii\  Later  the  mucosa  becomes  edematous.  The  vessels  of  the  inucosa 


LARYNGOSCOPY,    BRONCHOSCOPY,    KSOPHAGOSCOPY ,     I-7IC.  255 

arc  not  as  a  rule  visible.  Acute  inflammation  of  the  esophagus,  if  severe, 
is  a  contraindication  to  the  passage  of  the  esophagoscope.  When, 
however,  it  is  caused  by  the  presence  of  a  foreign  body  the  inflammation 
should  be  disregarded  and  the  foreign  body  removed  at  once.  In  acute 
inflammation  where  no  cause  is  found,  an  underlying  carcinoma  should 
be  suspected. 

Chronic  Inflammation  of  the  Esophagus  (Chronic  Esophagitis).— 
Chronic  inflammation  of  the  esophagus  may  follow  acute  inflammation 
but  as  a  rule  it  is  the  result  of  the  long  continued  irritation  of  pus 
or  food.  These  are  held  in  the  esophagus  by  spastic  or  anatomic 
strictures,  or  by  diverticula.  Uncomplicated  chronic  catarrhal  inflamma- 
tion of  the  esophagus  is  seen  most  often  in  alcoholics.  Here  it  is  due 
chiefly  to  the  irritation  of  the  local  irritant.  The  esophagus  is  usually 
a  dirty  gray  or  a  pale  red,  at  times  mottled  and  with  the  vessels  show- 
ing. Tenacious  mucus  covers  it. 

Ulceration  of  the  Esophagus. — Ulceration  of  the  esophagus  occurs 
in  two  forms,  ulcers  located  above  the  hiatus  and  ulcers  below  it. 


Fig.  194. 


Forceps  with  punch  tip  for  direct  work  upon  the  larynx  or 
esophagus.  This  forceps  is  made  in  various  lengths  so  that 
the  punch  can  be  adjusted  for  any  length  of  esophagoscope  or 
bronchoscope.  (Pfau.) 


Ulcerations  above  the  hiatus  may  be  due  to  any  of  the  causes  which 
produce  acute  inflammation  of  the  esophagus,  i.  e.,  to  infection  or 
trauma.  The  ulcers  occurring  in  typhoid  fever  are  caused  by  throm- 
bosis of  the  vessels.  Deep  painless  ulcerations  occur  in  syphilis.  The 
same  is  true  of  the  ulcerations  which  occur  in  tuberculosis.  The  greater 
part  of  the  esophagus  may  be  involved  in  tuberculosis  without  the 
lesion  being  suspected.  Tuberculosis  of  the  esophagus  usually  is  sec- 
ondary to  tuberculosis  of  the  lungs  and  is  due  to  swallowing  sputum.  A 
tuberculous  bronchial  gland  may  ulcerate  into  the  esophagus,  though 
this  happens  but  rarely. 

Ulcerations  of  the  esophagus  below  the  hiatus  bear  a  strong 
resemblance  to  peptic  ulcerations  of  the  stomach.  They  are  often 
assigned  to  functional  insufficiency  of  the  cardia.  Jackson  believes  that 
the  closure  of  the  upper  end  of  the  stomach  is  due  to  a  kinking  of  the 
esophagus  at  the  hiatus  and  that  the  kinking  is  caused  by  the  pressure 


"Job"  OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

of  the  contents  of  the  stomach  at  the  fundiis  and  by  the  structures 
about  the  hiatus.  The  contents  of  the  stomach,  however,  frequently 
invade  the  lower  part  of  the  esophagus.  Ulcerations  of  the  esophagus 
at  this  point  have  a  resemblance  to  ulcerations  of  the  duodenum  and 
may  have  the  same  pathology.  Codman  has  made  the  observation  that 
duodenal  ulcerations  are  often  associated  with  fissures  of  the  cardia. 
He  made  the  further  observation  at  autopsies  that  fissures  of  the 
cardia  were  not  uncommon.  The  analogy  is  at  once  suggested  between 
fissure  of  the  cardia  and  fissure  of  the  anus. 

Where  an  ulceration  cannot  be  explained  the  presence  of  a  buried 
foreign  body  should  be  considered. 

The  treatment  of  ulceration  of  the  esophagus  consists  first  and 
chiefly  in  the  removal  of  the  cause.  After  this  is  accomplished  the 
topical  application  of  nitrate  of  silver,  argyrol,  or  tannin  is  useful. 
The  same  procedure  is  advocated  for  the  peptic  ulcer.  The  ulcer  is 
cleaned  and  then  dusted  with  bismuth  powder  or  touched  with  nitrate 


Fig.  1 !»;-,. 

Mother's  curette  for  use  in  examination  by  the  direct 
method  of  the  upper  end  of  the  esophagus  and  the  larynx.  A 
similar  but  much  longer  curette  is  made  for  use  with  the  eso- 
phagoscopo.  In  dealing  with  malignant  diseases  these  instru- 
ments are  indispensable. 

of  silver.  There  is  no  danger  of  perforation  or  of  hemorrhage  if  the 
manipulations  are  carried  out  gently,  and  always  under  clear  vision. 

Neuroses  of  the  Esophagus. 

Sensory  Neuroses  of  the  Esophagus. --—The  diagnosis  of  a  sensory 
neurosis  of  the  esophagus  should  he  made  with  great  care.  Since  the 
advent  of  the  esopliagoscope  the  number  of  true  cases  of  sensory 
neuroses  of  the  esophagus  has  been  markedly  diminished.  A  routine 
examination  of  such  cases  will  reveal  a  large  number  of  instances  in 
.\  liich  the  symptons  have  a  real  anatomic  or  pathologic  basis.  The 
old  diagnosis  of  .u'lobns  hystericiis  should  never  pass  un<|uestioned. 
A  trifling  anatomic  ncculiaritv  like  a  partial  band  at  the  mouth  of  the 

I  . 

esophagus,  can  readily  cause  these  cases.  The  writer  feels  that  further 
study  of  the  upper  end  of  the  esophagus  will  show  that  such  bands 
are  frequent.  Small  ulcerations  from  trauma  could  cause  such  partial 
bands  or  adhesions.  Whether  caused  bv  trauma  or  bv  some  slight 


LARYNGOSCOPY,    BRONCHOSCOPY,     KSOIMI  AUOSCOI'Y,     K'l'C.  -•)  i 

irregularity  of  development  the  passage  of  a  good  si/cd  bougie  under 
the  old  method  of  treatment  would  break  the  band  and  clear  up  the 
symptoms  but  not  the  diagnosis.  In  order  to  make  the  diagnosis  as 
certain  as  modern  knowledge  can  make  it  the  esophagoscope  must 
be  passed  before  the  bougie. 

True  sensory  neuroses  include  hyperesthesia  of  the  esophagus, 
anesthesia,  and  paresthesia.  The  patient  groups  his  symptoms  under 
the  head  of  a  feeling  of  contraction  of  the  upper  part  of  the  throat  and 
difficulty  in  swallowing,  or  as  a  sensation  of  itching,  pricking  or  gen- 
eral uneasiness.  Except  in  cases  of  true  hysteria  sensory  neurosis  of 
the  esophagus  is  very  rare. 

The  appropriate  treatment  is  along  general  medical  lines. 

Paralysis  and  Paresis  of  the  Esophagus. —  In  cases  where  the  in 
nervation  of  the  esophagus  is  interfered  with,  all  solid  food  is  swal- 
lowed with  difficulty.  Fluids  are  usually  swallowed  easily.  At  times, 
even  fluids  may  go  down  with  difficulty  and  only  in  small  quantities. 
After  eating  there  is  pain  back  of  the  sternum  and  regurgitation  of 
mucus  or  food. 

Contrary  to  expectation  the  esophagoscope,  even  without  ether. 
readily  enters  the  esophagus  and  passes  easily  into  the  stomach.  The 
ease  with  which  it  passes  establishes  the  diagnosis,  because  in  spastic, 
stenosis  spasm  occurs  if  no  anesthetic  is  used,  and  if  there  is  an  anatom- 
ical stricture  this  persists  even  under  ether.  The  paralysis  may  be 
demonstrated  by  Stark 's  pill  experiment.  With  the  aid  of  the  esophag- 
oscope and  forceps  a  pill  or  capsule  is  placed  in  the  esophagus  27  cm. 
from  the  incisor  teeth.  If  the  peristalsis  is  normal  the  pill  will  be  car- 
ried into  the  stomach;  if  the  pill  remains  where  it  is  placed  a  paralysis 
or  an  abnormal  feebleness  of  the  esophageal  wall  exists. 

The  chief  causes  of  paralytic  conditions  of  the  esophagus  are  cen- 
tral nerve  lesions,  the  most  common  being  bulbar  paralysis,  and  the 
neuritis  which  follows  alcohol,  diphtheria,  and  lead  poisoning 

When  a  paralytic  condition  of  the  esophagus  is  suspected  a  neuro- 
logic examination  is  called  for,  and  if  such  a  condition  is  proved  the 
treatment,  of  course,  is  along  general  lines. 

Congenital  Anomalies  of  the  Esophagus. 

Congenital  anomalies  of  the  esophagus  occur  occasionally.  The 
esophagus  may  be  bifid  or  double  or  it  may  end  in  a  blind  pouch. 
Children  having  these  deformities  seldom  live  for  any  length  of  time. 
Karely,  a  fistula  joins  the  trachea  and  the  esophagus.  Cases  of  this 
kind  have  been  reported  and  the  patients  have  survived.  This  was 


258  OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 

possible  for  the  reason  that  a  valve-like  fold  of  mucous  membrane 
prevented  food  from  getting  into  the  trachea. 

Congenital  Stricture  of  the  Esophagus. — A  little  girl  about  a  year 
old  was  referred  to  the  author  with  the  history  that  she 
had  swallowed  a  "pacifier,"  and  had  had  almost  complete 
obstruction  to  swallowing  since  the  accident.  The  baby  was 
very  poorly  nourished  and  it  was  found  on  questioning  the  parents 
that  from  birth  she  had  continually  thrown  up  her  food.  It  was  sup- 
posed naturally  that  the  milk  was  not  of  the  proper  kind.  Both  the 
milk  and  the  physician  were  repeatedly  changed.  The  baby  just  man- 
aged to  survive  up  to  the  time  when  it  made  a  meal  of  the  "pacifier." 
It  speedily  vomited  the  rubber  nipple  which  was  on  the  end  of  the 
"pacifier."  Notwithstanding  this  it  could  not  retain  any  milk.  A  local 
specialist  passed  an  esophagoscope  and  through  this  introduced  a 
bougie  but  could  not  make  it  enter  the  stomach.  At  this  point  in  the 
case  the  author  saw  the  child.  The  X-ray  showed  a  small  round  body 
apparently  in  the  esophagus  and  at  the  level  of  the  bifurcation  of  the 
trachea.  This  was  supposed  to  be  a  bit  of  bone  from  the  "pacifier." 
On  examination  under  ether  this  bit  of  bone  was  neither  seen  nor 
felt,  but  instead  a  stricture  was  found.  This  was  at  the  level  of  the 
bifurcation  of  the  trachea  and  readily  admitted  a  Xo.  1(>  F.  bougie 
and  was  easily  dilated  up  to  Xo.  '20  F.  Subsequent  dilatations  carried 
the  lumen  of  the  stricture  to  L'b'  F.  After  a  few  days  the  baby  began 
to  retain  milk.  A  second  plate  showed  that  the  bit  of  bone  which  gave 
the  round  shadow  in  the  first  plate  had  disappeared  after  the  examina- 
tion. The  stools  were  searched  but  it  was  never  found. 

The  following  seems  to  be  a  reasonable  explanation  of  this  case. 
The  child  had  a  congenital  stricture  and  she  forced  its  discovery  by 
swallowing  the  rubber  nipple  from  the  "pacifier"  and  perhaps  a  bit 
of  bone  from  the  handle.  'Die  first  examination  pushed  the  piece  of 
bone  through  the  stricture  and  the  second  pushed  it  into  the  stomach. 
The  second  examination  determined  the  presence  of  the  stricture  and 
led  to  its  dilatation. 

Diverticulum. — A  diverticulmn  is  a  pouch-like  off-shoot  from  the 
esophagus.  The  so-called  traction  divert  iculum  is  the  easiest  of  ex- 
planation. It  is  caused  by  the  contraction  of  scar  tissue,  arising  from 
a  suppurating  gland  in  process  of  healing.  This  new  tissue  exerts  a 
] nil  upon  a  circumscribed  part  of  the  esophageal  wall  and  makes  a 
pouch.  In  certain  animals  pouches  and  dilatations  of  the  esophagus 
are  normal;  for  instance,  the  crop  and  the  dilatation  of  the  lower  por- 
tion of  the  esophagus  in  birds.  Something  of  this  tendency  to  variation 
in  form  mav  be  retained  in  man.  In  one  of  the  author's  cases  the 


LAHYXCOSCOI'Y,     HKONC  1 1  OSCOPY  ,     KSOIM  I'A<  ;oS( 'Ol'Y  ,     KTC.  '_'.")!) 

mouth  of  the  esophagus  was  very  wide  as  if  the  pharynx  extended  he- 
low  the  crieoid  cartilage  and  had  there  attempted  to  make  a  double 
esophagus,  the  unsuccessful  attempt  being  the  pouch. 

Diverticula  are  encountered  most  often  in  the  upper  part  of  the 
esophagus  near  the  crieoid  cartilage.  In  every  esophageal  examination 
the  possibility  of  finding  a  pouch  must  be  borne  in  mind  and  its  exist- 
ence ruled  out. 

Si/)>i}>tonis. — The  symptoms  of  a  small  pouch  are  not  marked 
enough  to  make  the  examiner  do  more  than  suspect  its  presence.  The 
chief  symptoms  are  slight  difficulty  in  swallowing  and  soon  after  eat- 
ing the  regurgitatiou  of  a  small  amount  of  undigested  or  putrid  food. 
Where  a  poucli  has  existed  a  long  time  and  has  dissected  its  way 
downward  between  the  muscles  of  the  neck  and  perhaps  into  the  chest 
the  symptoms,  although  of  the  same  general  character,  are  much  more 
marked.  It  is  impossible  from  the  symptons  to  differentiate  such  a 
case  from  one  of  phrenospasm  and  dilatation  of  the  esophagus. 

Diagnosis. —  If  the  presence  of  a  pouch  is  suspected  the  physician 
may  give  the  patient  bismuth  and  then  take  an  X-ray:  or  he 
may  give  the  patient  bird  shot  to  swallow  and  then  take  the  plate; 
or  he  may  pass  a  bougie.  The  bougie  on  its  first  introduction  meets 
with  an  obstruction  high  up  in  the  esophagus  and  then  if  it  is  with- 
drawn and  reiutroduced  it  enters  the  lumen  of  the  esophagus  and 
continues  on  into  the  stomach.  Xo  one  of  these  three  methods  is  as 
satisfactory  as  the  diagnosis  of  a  diverticulum  by  sight.  An  X-ray 
plate  of  an  esophagus  filled  with  bismuth  often  gives  the  impression 
of  a  pouch  where  none  exists.  This  is  due  to  spasm  of  the  esophageal 
wall.  Briinings  has  a  beaked  tubular  speculum  the  lower  half  of  which 
lias  a  slit  in  the  side.  In  using  this  the  attempt  is  made  to  engage  the 
beak  of  the  speculum  in  the  opening  of  the  esophagus  and  after  this 
has  been  located,  to  find  the  opening  of  the  pouch  by  examining  the 
esophageal  wall  through  the  slit  in  the  side  of  the  instrument. 

In  the  search  for  diverticula  the  ballooning  attachment  for  the  oval 
esophagoscope  is  of  the  greatest  service.  There  is  usually  no  trouble 
in  finding  the  pouch,  as  the  esophagoscope  goes  into  it  most  readily. 
Once  in  the  pouch,  the  examiner  sees  no  esophageal  lumen  ahead. 
Instead  there  is  an  unbroken  wall.  On  attempting  to  readjust  the 
long  axis  of  the  tube  to  conform  to  the  long  axis  of  the  esophagus 
still  no  lumen  appears.  If  now  the  window  plug  is  inserted  and  the 
pouch  distended  with  air  the  fact  that  the  end  of  the  esophagoscope 
is  in  a  closed  cavity  becomes  (dear.  Not  only  this,  but  the  size  of  the 
pouch  can  be  made  out  and  the  condition  of  its  walls.  The  bottom  of  the 
pouch  is  found  in  many  cases  to  be  thickened  and  inflamed  from  the 


OPERATIVE    STRCERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

retention  and  maceration  of  food.  When  the  pouch  has  been  outlined 
in  this  way  if  the  esopkagoscope  is  slowly  withdrawn,  and  all  the  while 
air  is  forced  into  the  pouch,  at  the  moment  when  the  end  of  the 
esophagoscope  leaves  the  month  of  the  pouch  and  is  opposite  the 
opening  of  the  esophagus  two  openings  will  be  seen  through  the 
tube.  The  new  opening  will  prove  on  examination  to  be  the  lost 
opening  of  the  esophagus.  This  is  by  far  the  best  method  of  determin- 
ing the  presence  of  a  diverticulum. 

Tr<'af  iiK'tit  of  Kxopliftf/cal  Diverticula. —  Lf  the  pouch  is  large 
enough  and  not  too  large,  that  is,  if  it  does  not  extend  into  the  chest, 
it  may  be  dissected  out.  This  is  the  treatment  advocated  at  the  Mayo 
hospital.  Small  and  medium  sized  pouches  may  be  cured  symp- 
tomatically  by  dilating  the  esophagus  at  the  point  where  the  pouch 
leaves  it.  This  is  done  by  first  finding  the  pouch  and  cleaning  it  of 
food  and  then  stretching  the  esophagus  with  the  mechanical  dilator. 
After  this  a  thread  is  passed  through  the  esophagus  into  the  stomach 
and  allowed  to  engage  in  the  upper  part  of  the  intestinal  tract.  As 
soon  after  the  ether  examination  as  the  thread  has  become  well  an- 
chored, the  metal  staff  of  Mixter  with  its  perforated  olive  is  carried 
down  on  the  thread  and  olives  of  increasing  size  are  forced  down  on 
the  staff.  After  a  week  or  two  the  metal  staff  will  find  the  esophageal 
opening  unguided  by  the  thread  and  the  thread  may  be  allowed  to 
pass  on.  The  physician  soon  finds  that  he  can  pass  elastic  bougies 
also  of  increasing  size,  through  the  esophagus.  .Lastly  the  patient,  is 
taught  to  pass  a  bougie  of  reasonable  size  for  himself.  This  has  to  be 
continued  for  an  indefinite  time.  Mixter  who  has  had  much  experience 
both  with  excision  of  the  pouch  and  with  the  symptomatic  cure  by 
dilatation,  favors  for  the  general  run  of  cases  the  treatment  by  dilata- 
tion. 

Some  day  it  may  seem  feasible  to  cut  the  common  wall  between  a 
small  pouch  and  the  esophagus.  When  this  procedure  is  attempted 
it  will  be  carried  out  if  it  is  to  be  performed  in  a  surgical  fashion, 
through  the  esophagoscope.  The  writer  tried  this  in  a  rather  hesitat- 
ing manner  on  one  case,  and  is  waiting  for  an  appropriate  case  to  try  it 
again.  The  results  were  mediocre,  i.  e.,  no  better  than  dilatation. 

Dilatation  of  the  Esophagus. 

In  dilatation  of  the  esophagus  the  whole  structure  becomes  en- 
larged and  acts  as  a  sac  instead  of  a  tube.  The  most  common  form 
is  a  spindle-shaped  esophagus.  From  certain  observations  the  au- 
thor is  of  the  opinion  that  a  dilatation  of  moderate  degree  of  the 


LAkYXdOSCOl'Y,     BKOXCIIOSCOI'Y,     KSOl'jIAdOSCOl'Y,     KTC. 

lower  third  of  the  esophagus  is  common,  it'  not  normal.  It  is  certainly 
not  unusual  in  dissecting  room  bodies. 

The  lower  part  of  the  esophagus  is  the  part  most  often  enlarged. 
The  dilatation  is  due  either  to  an  anatomic  stricture  or  to  a  spastic 
closure  at  some  point.  The  forms  of  stricture  have  been  discussed. 
Spastic  closure,  as  has  been  said,  is  due  as  a  rule  to  spasm  of  the 
hiatus  of  the  esophagus  or  to  spasm  of  the  cardia.  Dilatation  of  the 
esophagus  is  spoken  of  at  this  point  under  a  separate  heading,  and 
after  diverticula  of  the  esophagus  have  been  discussed,  because  tin- 
two  conditions  have  to  be  differentiated. 

The  diagnosis  is  made  by  examining  the  lumen  of  the  esophagus 
through  the  esophagoscope.  In  the  normal  esophagus  the  walls  hug 
the  examining  tube  and  are  seen  to  be  continuous  with  the  end  of  the 
tube  for  some  distance  ahead.  If  the  esophagus  is  dilated  the  end  of 
the  esophagoscope  finds  itself  in  a  large,  dark  cavern  the  walls  of 
which  become  clear  only  as  the  tube  is  moved  strongly  from  side  to 
side.  The  opening  of  the  esophagus  below  the  dilatation  may  not  be 
in  the  center  of  the  dilated  portion,  but  eccentric.  Not  only 
this,  but  the  dilated  portion  may  sag  below  the  level  of  the  esophageal 
opening  and  make  a  dee])  moat  about  it.  Most  often  the  sa.uging  of 
the  dilated  part  of  the  esophagus  below  the  opening  of  the  esophagus 
occurs  to  the  right  of  the  esophageal  opening.  It  is  into  this  sagging 
part  of  the  esophagus  that  the  point  of  the  examining  bougie  invariably 
finds  its  way,  and  it  is  at  this  point  that  perforation  of  the  esophagus 
from  rough  manipulation  with  bougies  occurs  most  frequently.  When 
this  pouch-like  collar  occurs  at  the  lower  end  of  the  esophagus  the  use 
of  a  metal  staff  with  an  olive  on  the  end  enables  the  examine]1  to 
swing  the  point  of  the  olive  to  the  left  and  to  iish  successfully  for  the 
opening  of  the  esophagus.  Ballooning  the  esophagus  smooths  the  folds 
and  makes  the  lumen  stand  out  clearly. 

The  treatment  of  dilatation  of  the  esophagus  is  to  treat  the  con- 
dition which  causes  it.  'Phis  has  already  been  given. 

Foreign  Bodies  in  the  Esophagus. 

.Jackson  begins  his  chapter  on  foreign  bodies  in  the  esophagus 
with  the  following  sentences:  "Considering  the  brilliant  achievements 
of  esophagoscopy  in  the  removal  of  foreign  bodies  from  the  esophagus, 
it  is  time  to  pronounce  the  prevalent  use  of  the  sound,  the  vertebrated 
forceps,  the  coin  catcher,  the  bristle  and  sponge  probangs  obsolete, 
dangerous,  unsurgical  and  utterly  unjustifiable.  There  are  numerous 
cases  on  record  of  fatal  results  from  their  use,  and  there  are  many 
times  as  many  cases  that  have  never  been  reported/'  This  language 


262  OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

is  none  too  strong,  especially  when  applied  to  the  use  of  these  instru- 
ments in  cases  of  rough  or  sharp  foreign  bodies. 

Foreign  bodies  lodged  in  the  esophagus  fall  naturally  into  two 
groups,  smooth  foreign  bodies  and  rough  or  pointed  ones.  In  the  first 
class  are  penny  whistles,  buttons  and  coins.  Prominent  in  the  second 
are  pins,  needles  and  safety  pins,  fish  bones,  chicken  bones,  meat 
bones,  and  lastly,  partial  or  complete  tooth  plates.  Coins  often  lodge 
for  a  while  and  then  go  down,  although  there  are  many  cases  in 
which  coins  have  failed  to  pass  into  the  stomach  but  have  remained 
in  one  position  and  ulcerated  into  the  aorta  or  trachea.  Pointed  and 
sharp  objects  as  a  rule  lodge  and  finally  perforate  and  generally  prove 
fatal. 

Ordinarily  patients  come  to  the  physician  with  the  history  that 
they  have  swallowed  a  foreign  body.  This  is  not  always  the  case, 
however,  because  it  sometimes  happens  that  they  come  simply  for 
difficulty  in  swallowing.  In  infants  regurgitation  of  food  may  be  the 
only  symptom.  Older  children  may  swallow  liquids  but  not  solid  food 
and  there  is  a  persistent  cough.  Patients  often  think  that  a  sharp 
foreign  body  is  still  in  the  esophagus  when  in  reality  it  has  passed 
downward.  The  scratch  or  abrasion  caused  by  it,  and  this  is  especially 
+rue  of  fish  bones,  for  some  days  makes  the  patient  feel  that  something 
is  wrong  and  lie  interprets  his  abnormal  sensations  as  the  continued 
presence  of  the  foreign  body.  Without  an  esophageal  examination  it 
is  very  hard  to  disabuse  the  patient  of  this  idea.  Patients  seldom 
localize  the  position  of  the  foreign  body  accurately. 

Places  Where  the  Foreign  Bodies  Lodge. — Foreign  bodies  in  the 
esophagus  lodge  most  often  back  of  the  cricoid  cartilage.  If  they  are 
dislodged  from  here  they  stop  again  at  the  level  of  the  inner  end  of  the 
clavicles.  Anatomic  narrowing  is  said  to  be  responsible  for  this.  Once 
beyond  the  clavicles  smooth  foreign  bodies  almost  always  find  their 
way  into  the  stomach  and  any  smooth  foreign  body  which  gains  the 
stomach  as  a  rule  can  pass  the  pylorus.  It  is  astonishing  how  large  an 
object  can  do  this.  The  author  has  known  a  flat,  mother-of-pearl 
button  one  inch  in  diameter  to  pass  from  the  stomach  of  a  one  year 
old  child  into  the  intestinal  tract  and  to  be  recovered  in  the  stools  in 
twenty-four  hours. 

Procedure  to  be  Followed  in  Cases  of  Foreign  Bodies. — The  his- 
tory of  the  case  is  taken  and  the  parents  or  the  friends  of  the  patient 
are  instructed  to  bring  a  duplicate  of  the  foreign  body  if  it  happens 
to  be  a  nail,  a  pin,  or  a  button.  The  physician  can  probably  furnish 
a  duplicate  it'  the  foreign  body  is  a  coin.  I'nless  the  case  happens  to 
be  desperate  from  pressure  upon  the  trachea  an  X-ray  plate  is  taken. 


LARYXfiOSCOPY,     JiHOXC  I  lOSCOI'Y,     KSOI'H  A(  ;<)S<  'Ol'Y,     KTC.  'H)',"> 

This  determines  tlie  position  of  the  foreign  body  and  in  case  its  nature 
is  not  known  often  discloses  it.  Next  appropriate  instruments  for  the 
extraction  of  the  foreign  body  are  selected  or  obtained.  Success  in  the 
removal  of  foreign  bodies  lodged  either  in  the  trachea  or  in  the  eso- 
phagus depends  upon  two  things,  the  mechanical  sense  and  dexterity 
of  the  operator,  and  suitable  instruments.  In  the  matter  of  instru- 
ments it  is  vitally  important  to  select  grasping  forceps  with  blades 
adapted  to  seizing  the  particular  foreign  body  in  hand.  (  Fig.  1!)(5.) 
On  the  duplicate  foreign  body  the  forceps  chosen  can  be  tested.  If  the 
duplicate  foreign  body  is  placed  in  a  piece  of  rubber  tubing  the  manip- 
ulations necessary  for  its  extraction  can  be  practiced.  Such  practice 
leads  to  siireness  and  confidence  and  these  in  turn  lead  to  success. 

Before  using  the  tubular  speculum  or  the  esophagoscopc  a  system- 
atic examination  is  made  with  head-light  and  mirror  of  the  patient's 
mouth  and  pharynx.  The  crypts  of  the  tonsils,  the  supratonsillar  fossa 


Fig.  196. 
Jackson's  foreign  body  forceps. 


and  the  vallecuhr  at  the  base  of  the  tongue  and  the  pyriform  sinuses 
are  examined  in  turn.  Impacted  concretions  in  the  supratonsillar  fossa 
often  give  the  sensation  of  a  foreign  body.  If  a  good  view  cannot  be 
obtained  after  cocainization  and  if  the  foreign  body  happens  to  be 
small  like  a  fish  bone  or  a  pin,  the  base  of  the  tongue  and  the  pyriform 
sinuses  are  explored  with  the  tip  of  the  finger.  Should  the  foreign  body 
happen  to  be  a  coin  this  manipulation  is  not  employed  for  fear  that 
the  gagging  caused  by  it  might  dislodge  the  coin  from  the  grasp  of 
the  mouth  of  the  esophagus  and  start  it  downward.  For  the  same 
reason  sounds  and  bougies  are  not  passed. 

Choice  of  the  Anesthetic. — After  the  examination  of  the  mouth 
and  pharynx  has  proved  negative  the  operator  decides  whether 
the  examination  with  the  tubular  speculum  is  to  be  carried  out  under 
local  or  general  anesthesia.  Many  successful  extractions  of  foreign 
bodies,  notably  in  the  German  clinics,  have  been  performed  under 
local  anesthesia.  Even  partial  tooth  plates  have  been  so  removed. 
Some  allowance  must  be  made  for  the  temperament  of  the  patient 


264 


OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 


and  also  for  the  temperament  of  the  operator.  The  author  has  re- 
peatedly expressed  his  individual  preference  for  general  anesthesia. 
If  the  operator  prefers  the  sitting  position  and  cocain  anesthesia, 
well  and  good,  provided  that  the  results  are  good;  if,  on  the  other 
hand,  he  should  prefer  general  anesthesia  and  the  prone  position  of 
the  patient  he  should  not  be  ruled  out  of  court. 

Coins  and  Buttons  in  the  Esophagus. — Coins  and  buttons  and  for- 


Fig.   11*7. 

Penny  lodged  in  the  upper  part  of  (ho  esophagus  of  a  child.  The 
penny  is  well  above  the  level  of  the  clavicles,  that  is,  it  is  just  below  the 
mouth  of  the  esophagus  and  opposite  the  cricoid  cartilage.  (X-ray  tracing 
retouched  and  reduced.  Drawing  made  by  the  author.  From  the  throat 
clinic  of  the  Massachusetts  (General  Hospital.) 

eign  bodies  of  similar  form  usually  lodge  behind  the  cricoid  cartilage. 
These  cases  usually  occur  in  children.  The  first  thing  which  the  physi- 
cian should  remember  when  he  encounters  such  a  patient  is  to  keep 
his  finger  out  of  the  child's  mouth.  (Fig.  1!»7.)  If  the  X-ray  plate  shows 
that  the  coin  is  sticking  behind  the  cricoid  cartilage  and  the  patient  is 
an  infant  or  ;i  young  child,  it  is  wrapped  in  a  blanket,  placed  on  its 
back  on  the  examining  table  and  the  head  is  brought  over  the  end  of 


L,AKYN<;OS('OI'Y,     BKOXCII  OSCOI'V ,     KSOIMI  A<  :OSC<  H'Y,     KTC.  -!b'5 

the  table  and  held  by  an  assistant.  II'  the  child  is  too  large  to  be  con- 
trolled, ether  is  given.  The  operator  has  a  choice  of  instruments  for 
bringing  the  coin  into  view,  the  closed  tubular  speculum  of  .Jackson 
or  Briinings  and  the  adjustable  speculum  of  the  author.  If  the  adjust- 
able speculum  is  selected  the  point  of  the  speculum  is  passed  under 
its  own  illumination  or  under  the  illumination  of  the  head  mirror — 
and  no  illumination  equals  that  of  the  head  mirror  for  short  distances 
—until  the  point  of  the  speculum  is  engaged  behind  the  ring  of  the 
cricoid  cartilage.  When  the  ericoid  cartilage  is  held  forward  it  is 
possible  to  see  down  the  lumen  of  the  esophagus  almost  to  the  level  of 
the  clavicles.  Coins  and  buttons  lie  flat  against  the  vertebral  column, 
so  that  the  operator  sees  only  the  upper  edge  of  the  rim  of  the  coin. 
This  appears  as  a  dark,  transverse  line.  The  edge  of  the  coin  being  in 
view  it  is  a  simple  procedure  to  pass  a  pair  of  angular  forceps  and  re- 
move it.  The  tubular  speculum  can  be  employed  in  the  same  way.  It 
does  not,  however,  give  such  a  wide  field  for  operating  as  the  adjust 
able  speculum.  If  the  coin  is  below  the  reach  of  the  speculum  an 
esophagoscope  of  appropriate  size  is  introduced  into  the  esophagus 
and  carried  down  carefully  until  the  foreign  body  conies  into  view. 
As  large  a  tube  should  be  used  as  possible,  because  it  is  humiliating 
yet  true,  that  a  small  bronchoscope  may  pass  a  coin  without  the  exam- 
iner seeing  it,  or  detecting  it  by  striking  it  with  the  end  of  the  tube. 
A  manipulation  which  will  occasionally  bring  the  coin  to  view  is  to 
elevate  the  handle  of  the  tube  strongly  and  to  press  the  point  against  the 
vertebral  column.  This  saved  the  author  on  one  occasion  from  the 
embarrassment  of  defeat  in  the  case  of  the  child  of  a  physician.  When 
a  button  or  a  coin  is  lodged  in  the  thoracic  portion  of  the  esophagus 
as  the  examining  tube  approaches  it  the  lumen  of  the  esophagus  changes 
from  the  customary  rosette  to  a  transverse  slit.  In  this  dark  trans- 
verse slit  the  foreign  body  is  lodged  and  is  holding  the  esophageal 
walls  apart.  The  first  grasp  of  the  forceps  upon  the  coin  should  be 
a  sure  one,  because  if  the  coin  is  nibbled  and  not  firmly  seized,  the 
operator  may  have  the  mortification  of  seeing  it  disappear  down  the 
esophagus.  If  he  catches  sight  of  it  again  he  is  fortunate;  generally 
it  has  gone  into  the  stomach.  If  before  or  during  the  examination 
the  patient  vomits,  examine  the  vomitus.  The  foreign  body  may  be 
found  in  this.  (Fig.  198.) 

The  Bristle  Probang. — The  use  of  the  bristle  probang  is  allowable 
only  in  case  a  bolus  of  meat  or  a  smooth  foreign  body  like  a  coin  or 
a  button  is  lodged  behind  the  cricoid  cartilage.  Its  use  in  such  cases 
is  often  successful  and  is  without  danger.  A  more  surgical  procedure, 
however,  is  to  use  the  speculum.  When  rough  foreign  bodies  like  fish 
or  chicken  bones  or  pins  are  to  be  dealt  with  the  use  of  the  bristle 


'266 


OPERATIVE    SUROERY    OF    THE    NOSE.    THROAT,    AND    EAR. 


probang  is  contraindicated.  In  the  rare  cases  in  \vliieh  the  use  of  the 
tubular  speculum  or  the  esophagoscope  fails  to  disclose  the  foreign 
body  the  bristle  probang  comes  again  to  its  own.  If  a  coin  or  a  button 
cannot  be  found  and  extracted  it  is  good  practice,  at  least  from  the 
standpoint  of  the  patient,  to  push  it  down.  Opening  the  side  of  the 
neck  for  the  removal  of  a  smooth  foreign  body  of  this  nature  is  obsolete 
surgery. 

Pins  in  the  Esophagus. — AVhen  a  pin  is  lodged  in  the  esophagus, 
especially  when  its  point  is  turned  downward,  it  does  not  as  a   rule 


Fig.  litS. 

Penny  whistle  in  the  upper  part,  of  the  esophagus  of  a  seven  year  old  child. 
The  whistle  lodged  just  below  the  mouth  of  the  esophagus  and  behind  the 
cricoid  cartilage.  This  is  the  favorite  plaee  for  foreign  bodies  to  halt.  The 
whistle  was  removed  under  ether  with  the  author's  open  speculum  and 
angular  forceps.  Such  cases  are  best  managed  with  the  tubular  or  the 
op<  n  speculum.  (Author's  case,  X-ray  tracing  retouched  and  reduced. 
Massachusetts  Charitable  Eye  and  Kur  Infirmary.) 


h  trouble  in  the  extraction.  When,  on  the  other  hand,  the 
of  the  pin  is  uppermost  and  embedded,  its  removal  may  be  very 
difficult.  ( 'asselberry 's  pin  cutter  which  divides  the  pin  and  holds  the 
fragments  is  practically  indispensable  for  the  propel1  management  of 
such  cases. 


l.ARYXOOSCOPY,     I5KOXC  1 1  OSCOI'Y  ,     KS( )!'  1 1  A< ;< )S(  '<  >I'Y  ,     KTC.  20  I 

Safety  Pins  in  the  Esophagus. —  (Fig.  11M).)  An  open  safety  pin, 
point  up,  is  ono  of  the  hardest  of  foreign  bodies  to  remove  from  the 
esophagus.  The  aim  of  the  operator  is  to  close  the  pin.  'Phis  ac- 
complished, the  extraction  is  easy.  Coolidgo,  some  eight  years  ago,  was 
ihe  first  to  remove  a  safety  pin  from  the  esophagus.  He  used  a  safety 
pin  closer  devised  by  the  author.  Since  the  time  of  this  case  other 
methods  have  been  devised  for  successfully  closing  a  safety  pin.  Within 
the  last  year  Jackson  has  introduced  a  daring  and  simple  method  of 
closing  and  extracting  a  safety  pin.  (Figs.  200  and  201.)  Through  the 
esophagoscopo  with  forceps  tipped  \\"ith  two  slender  interlocking  blades 
he  grasps  the  ring  of  the  pin.  When  the  blades  of  the  forceps  are 


Fig.   199. 

Safety    pin    in    the    esophagus.     Child    two    years    old.     Author's    case. 
Extraction   by   means  of  the   esophagoscope   failed   and   the  pin   was  pushed 
into  the  stomach  and  removed  by  incision.     The  child  died  of  pneumonia. 
(Plate  by"  Dr.   W.   J.   Dodcl.) 

locked  in  the  ring,  the  pin  is  carried  into  the  stomach  and  allowed  to 
turn.  Then  the  forceps  are  withdrawn  with  the  pin  he-ided  the  other 
way.  As  the  pin  conies  into  the  tube  it  closes.  The  author  has  devised 
a  safety  pin  tube  the  aim  of  which  is  to  close  the  pin  and  to  extract  it 
without  first  pushing  it  into  the  stomach. 

A  few  years  ago  the  author  originated  an  instrument  (Fig.  202) 
for  closing  an  open  safety  pin,  point  up.  The  device  consisted  of  a 
double  bronchoscope,  one  tube  being  placed  within  the  other.  The  outer 
tube  had  a  slit  in  the  side  which  engaged  the  pointed  shaft  of  the 
pin.  Rotation  of  the  inner  tube  closed  the  pin.  The  device  has  been 
simplified  by  discarding  the  inner  tube.  The  present  instrument  is 


268 


OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 


made  as  follows:  It  is  the  usual  self-lighted  bronchoscope.  There  are 
two  sizes,  the  smaller  one  for  the  trachea  and  the  larger  one  for  the 
esophagus.  The  end  of  the  tube  is  bevelled  on  the  side.  From  the  apex 
of  the  V  a  slit  runs  upward  about  two  inches.  At  the  summit  and  at 
the  side  of  this  there  is  a  second  smaller  and  connecting  slit.  A  pointed 
tongue  separates  the  two  slits. 

Suppose  for  the  sake  of  illustration  that  the  point  of  the  pin  is  up, 
and  imbedded  in  the  right  esophageal  wall.    The  tube  is  used  in  the 


Fi.il'.    L'UO. 

Jackson's  forceps  for  grasping  and  pushing  open  safety  pins  into  the 
stomach  for  turning.  A,  illustrates  point  of  forceps;  B,  illustrates  method 
of  procedure. 


Fig.  2U1. 

Schema  showing  Jackson's  method  of  removing  an  open  safety  pin  from 
the  esophagus  by  passing  it  into  the  stomach,  where  it  is  turned  and  removed. 
The  first  illustration  (A)  shows  forceps  before  soi/.ing  pin  by  the  rings  of 
the  spring  end.  (Forceps  jaws  are  shown  opening  in  the  wrong  piano.)  At 
H  is  shown  the  pin  seix.ed  at  the  ring  by  the  forceps.  At  ('  is  shown  the  pin 
carried  into  the  stomach  and  about  to  be  rotated  by  withdrawal.  I),  the 
withdrawal  of  the  pin  into  the  esophagoscope  which  will  thereby  close  it. 
I  From  the  Laryngoscope.) 


LARYNGOSCOPY,    BROXCIIOSCOl'Y,     KSOIMI  AUOSCOI'Y,     KTC. 


•JG9 


following  manner:  It  is  carried  into  the  esophagus  until  the  hood  of 
the  pin  can  be  seen.  This  is  grasped  with  forceps  and  steadied  while 
the  slit  is  turned  so  that  il  engages  the  pointed  shaft  of  the  pin.  Then 
the  tube  is  pushed  onward  until  the  top  of  the  slit  brings  up  against 
the  crotch  of  the  safety  pin.  This  stage  of  the  manipulations  reached 
the  tube  is  carried  a  little  further  down  in  order  to  free  the  point  of  the 
pin  from  the  esophageal  wall.  This  accomplished  the  hood  of  the  pin 
is  again  held  motionless  by  the  forceps  while  the  barrel  of  the  tube  is 
rotated  to  the  right.  By  this  manipulation  the  shaft  which  bears  the 
point  of  the  pin  is  made  to  lie  in  line  with  the  accessory  slit.  The 
pin  is  now  pushed  straight  down  the  tube.  As  it  descends  the  accessory 
slit  which  of  course  is  closed  below  acts  as  a  ring  and  shuts  the  pin. 


Fig.  202. 

Mosher's  safety  pin  removing  tube.  1.  end  of  safety  pin  closing  tube. 
2,  hood  of  pin  grasped  through  tube.  3.  tube  carried  down  until  main  slit 
brings  up  against  the  crotch  of  pin.  4,  barrel  of  tube  rotated  to  the  right 
in  order  to  bring  pin  in  line  with  secondary  slot.  5,  pin  pushed  down  and 
closed. 

The  tube  and  the  pin  are  withdrawn  together.  .V  moment's  practice 
outside  of  the  body  will  show  that  these  manipulations  which  seem 
complicated  when  described  are  in  reality  very  simple. 

Uubbard  has  devised  a  useful  loop  guide  for  the  wire  snare,  and 
employed  it  successfully  for  the  closing  and  removal  of  a  safety  pin. 

Tooth  Plates  in  the  Esophagus. — Tooth  plates,  especially  partial 
plates  with  prongs,  have  the  unpleasant  distinction  of  being  the  hardest 
foreign  bodies  which  the  physician  is  called  upon  to  remove  from  the 
esophagus.  Many  successful  extractions  of  tooth  plates,  however,  have 


270 


OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 


been  recorded.  (Fig-.  204.)  It  is  an  axiom  in  dealing  with  these  difficult 
cases  that  unless  the  extraction  is  fairly  easy  and  is  soon  accomplished 
the  forein  bod  should  be  removed  b  an  incision  throuh  the  side 


Fig.  203. 
Alosher's   safety   pin    forceps. 

of  the  neck.  It  should  be  remem- 
bered, however,  that  the  mortal- 
ity of  this  procedure  is  12-20  per 
cent  or  ten  times  the  mortality  of 
esophagoscopy.  Rough  manipu- 
lation is  not  permissible.  The 
chief  difficulty  presented  by  these 
cases  is  the  locking  of  the  prongs 
of  the  plate  in  the  tissues.  Some- 
times the  plate  can  be  turned  by 
careful  manipulation  so  that  its 
short  diameter  may  lie  in  the 
direction  of  the  esophageal  ax- 
is. Killian  accomplished  the  as- 
tounding feat  of  cutting  a  plate 
in  two  by  g'alvanocauterv.  Hather 


Tooth   plate  in   the  esophagus. 
Dr.    \V.  .}.    Dodd.) 


than  attempt  to  turn  the  plate  it 
is  better  surgery,  unless  the  turn- 
ing should  prove  to  be  easy,  to 
cut  the  plate.  For  this  a  power- 
ful for'-eps  is  necessary.  A  cut- 
ling  forceps  has  been  devised  by 
Kahler.  The  one  devised  by  the 
author  is  illustrated  in  Tig.  20."). 
The  loolh  plate  should  be  at- 
tacked early  before  the  irritation 
set  ii})  by  it  has  caused  the  eso- 
phageal  wall  to  become  inflamed 
and  edematous.  When  this  has 
occurred  it  is  hard  to  get  a  good 
view.  l>riinings  has  invented  a 
dilating  esopliagoscope  for  use  in 
t  hese  cases. 


LARYNOOSCOPY.     BRONCHOHCOPY.     KSOPH  ACOSCOl'Y ,     KIC. 


•27} 


After  all  esophageal  examinations,  and  especially  after  the  manip- 
ulations necessary  for  the  dilatation  of  a  stricture,  or  for  the  removal 
of  a  foreign  body,  the  patient,  complains  of  a  sore  throat.  Sometimes 
this  is  severe  and  makes  the  swallowing  of  food  difficult  for  a  few  days. 
After  the  stretching  of  a  stricture  there  may  he  pain  along  the  course 
of  the  esophagus  and  sharp  pain  in  the  epigastrium.  Also  there 
may  he  a  rise  of  temperature  for  twenty-four  hours.  Now  and  then 
there  is  emphysema  of  the  side  of  the  neck.  These  unpleasant  symp- 
toms, which,  put  in  perspective,  must  he  regarded  as  trivial,  soon  dis- 
appear under  simple  treatment. 


Fig.  205. 

Mosher's  instrument  for  cutting  a  tooth  plate  or  large  pieces 
of  bone.  A  smaller  instrument  of  this  same  pattern  can  be  had 
for  bending  pins  double  and  extracting  them. 


GASTROSCOPY. 

History. — In  1S81  Mikulicx,  who  did  so  much  pioneer  work  in 
esophagoscopy,  decided  after  experimentation  that  the  ^astroscope  must 
be  rigid.  The  men  who  had  attacked  the  problem  of  gastroscopy  be- 
fore this  time  had  used  instruments  which  were  jointed.  .Mikulicx, 
however,  placed  a  bend  in  his  ^astroscope  in  order  that  it  might  accom- 
modate itself  to  the  curve  of  the  vertebral  column.  His  instrument 
was  closed  and  the  picture  of  the  gastric  mucosa  was  produced  by 
prisms  after  the  fashion  of  the  cystoscope.  Rosenheim  also  worked 
with  a  rigid  tube  but  he  discarded  the  bend.  In  the  construction  of  his 
tube  lie  also  made  use  of  lenses  and  prisms.  It  remained  for  .Jackson, 
using  a  straight  instrument  without  optic  apparatus,  to  make  gastro- 
scopy  feasible  and  comparatively  easy.  He  elongated  the  esophago- 
scope  of  Kinhorn  and  added  a  drainage  tube  on  the  side.  He  dem- 
onstrated that  such  an  instrument  could  be  passed  into  the  stomach 
readily,  and  laid  down  the  axioms  of  modern  gastroscopy,  namely: 
The  gastroscope  must  be  passed  by  sight.  The  stomach  should  be 
examined  in  the  collapsed  state  to  permit  cleaning  of  the  mucosa  by 
mopping,  and  to  enable  the  operator  to  palpate  the  walls  of  the  stomach 
with  the  end  of  the  instrument.  General  anesthesia  is  indispensable  in 
order  to  prevent  retching.  When  this  occurs  the  diaphragm  clutches 
the  tube  and  defeats  the  examination. 

Usefulness  of  Gastroscopy. — Modern  gastroscopy  after  the  method 
of  Jackson  is  a  relatively  new  procedure,  so  that  the  part  that  it  is  to 


OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

play  in  surgery  has  not  yet  been  determined.  All  endeavor  in  this  line  is 
still  pioneer  work.  When  the  physician  in  making  a  diagnosis  is  able  to 
substitute  sight  for  touch  he  has  made  a  gain  almost  too  great  to  meas- 
ure. Gastroscopy  by  the  Jackson  method  has  actually  done  this.  It 
follows,  therefore,  that  it  is  of  the  greatest  service  in  determining  the 
presence  of  cancer  and  in  locating  ulcers.  By  this  method  it  is  possible 
also  to  remove  certain  foreign  bodies  from  the  stomach. 

The  cry  of  the  surgical  world  in  cases  of  cancer  is,  ''Make  the 
diagnosis  early."  When  cancer  of  the  stomach  is  suspected  let  the  sur- 
geon therefore  turn  to  the  gastroscope. 

Instruments. — The  gaslroscope  of  Jackson  is  a  long  esophagoscope. 
(Fig.  206.)  Frequently  in  order  to  examine  the  stomach  the  tube  must 
be  80  cm.  in  length.  For  many  cases,  however,  70  cm.  is  sufficient.  Such 
a  tube  can  be  lighted  satisfactorily  only  in  one  way,  that  is,  by  a  light 
at  the  far  end.  This  means  that  the  tube  must  be  of  the  self-lighted 
pattern.  The  diameter  of  the  adult  tube  is  10  mm.  Jackson  states 
that  he  frequently  uses  a  tube  whose  outside  dimensions  are  1 1  mm.  in 

. J 


Fig.   206. 
Jackson's  bronchoscope,  esophagoscope  and  gastroscope. 

one  diameter  and  14  in  the  other.  The  distal  end  of  the  tube  is  made 
in  the  form  of  a  thickened  ring  in  order  to  prevent  injury  of  the  tis- 
sues. The  tube  is  fitted  with  an  obturator  the  conical  end  of  which  pro 
jects  beyond  the  gastroscope  and  makes  the  introduction  easier.  An 
elastic  bougie  somewhat  longer  than  the  gastroscope  can  be  employed 
instead  of  the  obturator. 

The  Technic  of  Gastroscopy. — (Jelieral  anesthesia  is  essential  for 
the  proper  performance  of  gastroscopy  and  deep  anesthesia  is  neces- 
sary to  prevent  retching  and  to  relax  the  fibers  of  the  diaphragm  at 
the  point  where  the  esophagus  passes  through  it. 

The  patient  is  given  the  usual  surgical  preparation.  Food  is 
withheld  for  twelve  hours  in  order  that  the  stomach  may  be  as  empty 
as  possible.  Washing  out  the  stomach  is  not  a  satisfactory  substitute 
for  fasting. 

The  Position  of  the  Patient.  Jackson  in  his  earlier  work  had  the 
patient  placed  on  his  back  and  in  a  position  half  way  between  the  Tren- 
delenburu-  and  the  horizontal  posture.  This  causes  the  fluid  remaining 
in  the  stomach,  and  it  is  never  possible  to  get  the  stomach  completely 
dry  except  by  mopping  through  the  gastroscope,  to  drain  from  the 


LARYXCJOSCOI'Y,    JiHONCHOSCOl'Y,     ESOPU  At  i()SC()l'\  ,     KTC.  -l'.\ 

stomacli  by  gravity.  Of  late  Jackson  lias  elevated  the  head  of  the  table 
after  the  introduction  of  the  tube  so  that  the  operator  can  examine 
at  his  ease.  In  the  final  position,  the  head  of  the  table  is  about  .'50 
cm.  higher  than  the  foot.  The  assistants  are  placed  as  in  bronchoscopy 
or  esophagoscopy.  The  second  assistant  holds  the  head.  This  is  a  very 
responsible  position.  Boyce  who  has  long  assisted  Jackson  has  given 
much  study  to  this  detail  of  the  examination.  The  following  state- 
ment of  the  method  in  which  the  second  assistant  should  manage  the 
head  is  taken  from  a  detailed  description  given  by  Boyce.  The  mouth, 
pharynx  and  esophagus  are  brought  into  a  straight  line  not  by  the  lev- 
erage of  the  tube  but  by  the  position  of  the  patient's  head.  The  head 
is  held  steadily  in  extreme  extension  and  the  mouth  is  kept  widely  open. 
The  jaws  are  kept  apart  by  a  gag  placed  in  the  left  corner  of  the  mouth. 
The  assistant  who  holds  the  head  also  keeps  the  gag  in  place. 

The  patient  is  drawn  toward  the  operator  until  his  shoulders  are 
clear  of  the  operating  table  by  four  or  six  inches.  The  gag  is  inserted 
on  the  left  side.  The  assistant  sits  on  the  right  of  the  patient  on  a  stool. 
His  right  leg  is  held  in  the  kneeling  position  while  the  left  foot  is  sup- 
ported on  a  stool  26  inches  lower  than  the  top  of  the  table.  The  assist- 
ant's right  forearm  is  passed  beneath  the  neck  of  the  patient  and  sup- 
ports it.  The  right  hand  grasps  the  mouth  gag  and  keeps  it  from  slip- 
ping. The  left  hand  of  the  assistant  rests  on  his  left  knee  and  grasps 
the  top  of  the  patient's  head  and  at  the  same  time  bends  it  backward 
and  upward.  The  exact  amount  of  backward  bend  and  of  upward  pres- 
sure required,  is  determined  by  experience  on  the  individual  case. 

Passing  the  Gastroscope. — The  gastroscope  should  be  passed 
gently.  If  the  tube  does  not  advance  readily  its  position  is  wrong  and 
it  should  be  changed.  The  tube  must  be  well  lubricated  with  vaselin. 
The  gastroscope  is  grasped  and  held  by  the  right  hand  of  the  operator 
after  the  manner  shown  in  Fig.  207  (Jackson). 

The  forefinger  of  the  physician's  left  hand  is  introduced  into  the 
right  pyriform  fossa  of  the  patient  and  the  end  of  the  gastroscope  is 
carried  down  with  the  finger  as  a  guide.  As  the  tube  descends  a  cer- 
tain amount  of  upward  leverage  is  made  with  it  on  the  base  of  the 
tongue  and  the  epiglottis  and  finally  on  the  cricoid  cartilage.  The 
finger  of  the  physician  can  seldom  feel  the  cricoid  cartilage  in  the  adult. 
This  is  immaterial  because  once  the  end  of  the  gastroscope  is  well  in- 
serted in  the  right  pyriform  sinus  it  drops  readily  into  the  esophagus, 
provided  there  is  no  disease  at  this  point.  Disease  at  the  beginning  of 
the  esophagus  should  have  been  excluded  previously  by  the  use  of  the 
laryngeal  mirror.  If  this  has  not  been  done  it  is  excluded  at  the  time 
by  examination  with  the  speculum.  It  is  seldom  necessary  to  pass  a  flex- 
ible bougie  through  the  tube  and  into  the  esophagus  to  serve  as  a  guide. 


274 


OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAE. 


After  the  tube  has  slipped  into  the  esophagus  the  head  of  the  pa- 
tient is  raised  slightly,  the  obturator  is  withdrawn  and  the  current  for 
lighting  is  turned  on.  From  now  on  the  tube  is  passed  by  sight.  The 
esophageal  lumen  must  be  made  out  ahead  of  the  tube  before  it  is 
advanced.  AVith  each  inspiration  the  esophagus  opens  and  guides  the 
tube  in  the  right  direction.  The  end  of  the  gastroscop*'  is  kept  in  the 
long  axis  of  the  esophagus,  and  not  pointed  strongly  upward  for  fear 
of  collapsing  the  trachea.  After  the  introitus  has  been  passed  only  two 
points  give  trouble.  The  first  is  the  hiatus  of  the  diaphragm,  the  sec- 
ond the  subphrenic  portion  of  the  esophagus.  The  hiatus  is  passed  by 
making  the  long  axis  of  the  elliptical  tube  correspond  with  the  long 
axis  of  the  hiatus.  The  axis  of  the  hiatus,  as  has  been  said,  is  oblique 
from  behind  forward  and  from  right  to  left.  It  helps  very  much  if  the 
hiatus  is  partially  or  fully  closed  as  the  tube  approaches  it.  If  it  is,  the 


Position   of  the  right   hand   during  the  introduction   of  the  ^astroscope, 
viewed    from   above  by  the  operator   looking   downward.      (After  Jackson.) 

observer  sees  a  central  rosette-like  opening  ahead  of  the  tube.  The 
esophagus  leading  down  to  this  is  smooth.  (Fig.  l(i!>.)  The  end  of  the 
tube  is  placed  against  this  opening  and  then  a  little  pressure  or  a  little 
deepening  of  the  anesthesia  allows  the  tube  to  slip  through  into  the 
abdominal  portion  of  the  esophagus.  The  picture  seen  through  the 
tube  at  once  changes.  Instead  of  smooth  walls  as  before,  the  esophagus 
is  now  thrown  into  long,  thick  folds  which  center  at  the  left  of  the  field. 
(Fig.  170.)  Xo  regular  opening  is  made  out  but  if  the  end  of  the  tube 
is  crowded  to  the  left  and  advanced  slowly  the  folds  part  and  the  irreg- 
ular dark  slit  suddenly  bursts  open  and  the  tube  is  in  the  stomach.  If 
the  cardiac  opening  of  the  esophagus  is  in  a  state  of  spasm  the  long 
longitudinal  folds  of  the  abdominal  esophagus  swing  from  left  to  right 
and  radiate  from  a  small  circular  opening  which  is  placed  in  the  left 
ouadrant  of  t he  field. 


LARYXOOSCOI'Y,     1MOXC  1 1  <>S( '()!'  V  ,     KSOIMI  A<  lOSCOl'Y ,     KTC.  275 

Iii  order  to  pass  the  abdominal  esophagus  it  is  necessary  sometimes 
to  bend  the  head  and  neck  of  the  patient  to  the  right.  Full  anesthesia 
is  necessary  for  passing  the  hiatus,  the  subphrcnic  portion  of  the  eso- 
phagus and  the  cardiac,  opening. 

When  the  gastroscope  has  entered  the  stomach  it  is  necessary, 
owing  to  the  small  field  given  by  the  tube,  to  have  a  system  in 
the  examination.  There  are  two  plans  of  exploration.  First  the  ^as- 
troscope is  carried  straight  down  to  the  greater  curvature,  inspecting 
on  the  way  a  strip  of  the  anterior  and  the  posterior  walls.  If  the  stom- 
ach is  not  sufficiently  collapsed  one  wall  must  be  taken  at  a  time.  After 
the  first  strip  lias  been  gone  over  the  end  of  the  tube  is  moved  slightly 
to  one  side  and  brought  up  and  a  new  set  of  folds  examined.  This  is 
repeated  until  the  pyloric  limit  is  reached. 

As  much  of  the  stomach  as  possible  is  examined  strip  by  strip. 
Then  the  second  method  of  examination  is  practiced.  This  consists  in 
passing  the  tube  down  to  the  extreme  left  of  the  greater  curvature  and 
then  swinging  it  along  the  line  of  the  greater  curvature  to  the  riu'lit. 
Having  reached  the  right  limit  the  tube  is  withdrawn  a  little  and  swung 
back  like  a  pendulum.  In  this  way,  retreating  step  by  step  and  swing- 
ing the  end  of  the  tube  back  and  forth  from  right  to  left,  the  examina- 
tion is  continued  until  the  cardia  is  reached.  The  examination  is 
greatly  aided  by  having  an  assistant  manipulate  by  palpation  the  unex- 
plored portions  of  the  stomach  in  front  of  the  end  of  the  tube.  For 
this  purpose  the  patient  may  be  turned  first  on  one  side  and  then  on 
the  other.  During  these  manipulations  the  tube  is  withdrawn  into  the 
esophagus  and  then  pushed  into  the  stomach  again  when  the  new  posi- 
tion of  the  patient  lias  been  adjusted.  If  the  patient  begins  to  retch 
when  the  tube  is  in  the  stomach  it  is  withdrawn  into  the  esophagus 
above  the  diaphragm. 

The  vertical  diameter  of  the  stomach  is  determined  by  measure- 
ment. The  distance  from  the  teeth  to  the  cardia  is  ascertained  and 
then  the  gastroscope  is  pushed  down  to  the  greater  curvature  and  the 
distance  from  the  teeth  determined  again.  The  difference  between  the 
two  measurements  is  the  vertical  diameter  of  the  stomach.  In  these 
manipulations  it  is  necessary  to  avoid  pushing  the  greater  curvature 
downward. 

The  smallest  vertical  diameter  found  by  Jackson  in  an  adult  was 
4  cm.  (one  and  one-half  inches)  and  the  greatest  .'5(1  cm.  (fourteen 
inches). 

The  end  of  the  tube  tends  to  drag  the  stomach  walls  along  with  it. 
This  can  be  avoided  by  withdrawing  the  tube  a  little  and  then  carrying 
it  down  again.  The  average  time  required  to  examine  the  stomach  is 
thirtv  minutes. 


I'Tf)  OPERATIVE    srR(iEHV    OF    THE    NOSE,    T1IHOAT.    AND    EAR. 

The  Area  of  the  Stomach  Which  Can  be  Explored. — Vertical  and 
infantile  stomachs  afford  the  greatest  range  of  exploration.  The  more 
horizontal  the  stomach  the  less  the  range.  The  lateral  movement  of 
the  hiatus  makes  it  possible  to  examine  the  stomach  over  an  extended 
area.  This  lateral  movement  varies  with  the  individual.  It  is  great- 
est in  feeble,  elderly  and  emaciated  patients.  Also  the  deeper  the  anes- 
thesia the  greater  it  is.  The  anteroposterior  mobility  of  the  hiatus  is 
of  but  little  use.  If  the  diaphragm  were  rigid  gastroscopy  would  lie 
much  limited.  Owing  to  its  flexibility  the  end  of  the  tube  can  be  made 
to  pass  at  the  hiatus  through  an  ellipse  the  small  diameter  of  which  is 
f)  cm.  and  the  large  diameter  15  cm.  The  long  axis  of  this  ellipse  is 
placed  laterally. 

The  full  range  of  the  thoracic  aperture  is  made  available  by  shift- 
ing the  head  and  the  neck  to  the  side.  The  pivotal  or  rocking  point  of 
the  gastroscope  is  in  the  thorax  not  at  the  beginning  of  the  esophagus 
or  at  the  hiatus. 

As  a  rule  the  tube  can  be  made  to  point  in  turn  to  either  superior 
spine  of  the  ilium  and  the  greater  curvature  can  be  forced  down  to  this 
level. 

Any  anomaly  or  disease  of  the  esophagus  may  render  gastroscopy 
difficult  or  impossible. 

Contraindications. — The  contraindications  to  gastroscopy  are  the 
usual  conditions  which  make  the  giving  of  an  anesthetic  unsafe. 

Dangers. — The  dangers  of  gastroscopy  in  careful  hands  are  only 
the  risks  of  the  anesthesia.  The  observations  of  Boyce  show  that  the 
blood  pressure  falls  when  a  rigid  tube  is  introduced  into  the  esophagus. 
This,  however,  lasts  only  a  short  time.  As  esophagoscopy  and  gastro- 
scopy are  done  by  sight  there  is  less  danger  than  in  the  passing  of  a 
sound. 

Difficulties. — Any  physician  who  has  had  a  training  in  the  use  of 
the  microscope  can  look  through  the  gastroscope  and  see  the  picture 
which  it  presents.  If  he  has  not  had  this  training  it  takes  a  little  time 
for  him  to  teach  his  eye  to  see. 

Lordosis,  Potts'  disease  and  other  diseases  of  the  spine  make  gas- 
troscopy impossible. 

The  Stomach  as  Seen  Through  the  Gastroscope. 

The  Normal  Stomach.  The  folds  of  the  stomach  are  constantly 
changing  so  thai  no  two  views  are  alike.  When  the  gastroscope  enters 
the  cardiac  opening  the  folds  extend  straight  on  from  the  mouth  of  the 
tube  and  a  small  tunnel  of  open  stomach  is  seen.  As  the  tube  is  carried 
down  through  this  the  folds  take  a  lateral  bend.  Finally,  the  tube 
brings  up  against  the  stomach  wall.  This  appears  as  a  flat  surface 


LARYXtJOSCOPY,     BRO.NC  1 1  OS<  'OI'Y  ,     KSOl'I  I  A<  i()SC(  >\'\  ,     KIT. 

which  is  sometimes  mottled,  sometimes  slightly  red.  The  greater 
curvature  allows  the  tube  to  push  it  downward  some  10  cm.  be- 
fore it  resists.  When  the  tube  is  withdrawn  the  stomach  wall  which 
has  been  flattened  against  it  follows  the  lube  upward  to  the  position 
whore  the  tube  first  encountered  it  or  a  little  higher.  As  yet  not 
enough  is  known  about  the  arrangement  of  the  folds  to  attempt  to 
group  them. 

The  mucosa  of  the  esophagus  and  that  of  the  stomach  at  times  are 
strongly  contrasted  in  color.  The  color  of  the  esophagus,  however,  is 
more  constant.  The  esophagus  is  generally  a  pale  pink  whereas  the 
mucosa  of  the  stomach  varies  from  a  similar  pink  to  a  deep  crimson. 
Jackson  considers  that  the  color  of  the  empty  stomach  varies  from  a 
pale  red  to  a  pale  pink.  The  mucosa  appears  moist  and  glistening  but 
less  transparent  than  the  mucosa  of  the  esophagus.  In  the  walls  of 
the  empty  stomach  vessels  are  not  usually  visible. 

The  pylorus  is,  of  course,  found  on  the  right  extremity  of  the 
greater  curvature.  As  the  tube  approaches  the  folds  guarding  it  it 
seems  like  a  slit.  This  gives  way  when  the  tube  lias  fully  reached  the 
opening,  and  a  round  opening  appears  somewhat  like  the  rosette  made 
by  the  esophagus  at  the  hiatus.  The  observer  makes  sure  that  the 
opening  is  the  pylorus  by  advancing  the  tube  into  it  until  the  small 
annular  folds  of  the  duodenum  come  into  view.  If  bile  colored  fluid 
escapes  upward  at  this  point  the  localization  of  the  pyloric  opening  is 
determined  beyond  a  doubt. 

The  Movements  of  the  Stomach. — Beside  the  ordinary  peristaltic 
movements  of  the  stomach  there  are  movements  associated  with  the 
heart  and  with  respiration. 

The  movements  transmitted  from  the  heart  are  best  seen  just  as 
the  tube  enters  the  cardia.  They  come  from  the  heart  and  the  descend- 
ing aorta  and  are  synchronous  with  the  beat  of  the  heart  and  the  blood 
wave  in  the  aorta. 

The  respiratory  movements  in  the  stomach  are  less  marked  than 
in  the  esophagus.  Just  as  in  the  esophagus,  there  is,  in  turn,  a  nega- 
tive and  a  positive  pressure.  This  alteration  causes  an  inflow  and  an 
outflow  of  air. 

'Jlif  I'frixtdltic  Mur<'uicntx. — The  peristaltic  movements  of  the 
stomach  which  result  from  the  action  of  its  own  fibres  can  he  fre- 
quently soon.  Those,  however,  are  not  as  marked  as  the  antiporistaltic 
movements.  The  latter  are  of  two  kinds,  the  reversed  peristaltic  move- 
ment which  is  seen  mostly  at  the  fundus  and  causes  vomiting,  and  the 
antiperistaltio  movement  of  the  duodenal  variety  which  is  confined  to 
the  region  of  the  pylorus. 

The  pylorie  third  of  the  stomach  is  the  most  unstable  part.  Jack- 


L'7S  OPERATIVE    STRCEHV    OF    THE     NOSE,    THROAT.    AND    EAR. 

son's  description  of  the  aperture  seen  through  the  tube  as  it  approaches 
the  pylorus  states  that  in  one  instance  the  pylorus  was  surrounded  by  a 
rosette  of  annular  folds.  In  another,  the  folds  were  larger.  These 
curved  in  ahead  of  the  tube  and  then  were  pushed  aside  by  it.  Finally, 
one  la  rye  fold  was  encountered  and  when  this  was  thrust  aside  a  slit 
came  into  view.  This  changed  at  once  into  a  rounded  opening  which 
was  the  entrance  to  a  short  tunnel  in  the  lumen  of  which  there  were 
numerous  small  folds.  From  this  opening  and  the  tunnel  beyond 
some  bile-like  fluid  welled  up. 

Gastritis. — Jackson  thus  describes  the  gastroscopic  findings  in  a 
case  of  gastritis.  The  walls  of  the  stomach  were  covered  with  a  thick 
pasty  secretion  and  the  folds  were  thickened.  In  another  case  the 
secretion  was  in  patches.  In  still  another  case  the  color  of  the  mucosa 
seemed  darker  red  than  the  normal.  In  only  one  case  did  this  observer 
find  dilated  capillaries  such  as  are  seen  in  chronic  inflammation  of  the 
esophagus. 

Peptic  Ulcer. — .Jackson  has  had  the  courage  to  examine  the  stom- 
ach in  cases  of  ulcer.  He  reports  his  findings  as  follows:  The  first 
ulcer  was  a  dirty  grayish-yellow  and  was  not  punched  out.  The  ulcer 
of  the  second  case  was  punched  out  and  had  slightly  infiltrated  edges. 
In  another  case  the  ulcer  appeared  as  a  longitudinal  slit.  In  still  an- 
other the  bed  of  the  ulcer  was  dark  and  rough. 

Malignant  Disease  of  the  Stomach. — Malignant  disease  of  the  stom- 
ach gives  a  varying  picture  in  different  parts  of  the  stomach  and 
in  different  parts  of  the  same  growth.  There  is  a  striking  contrast 
between  the  mucosa  over  a  cancerous  infiltration  and  the  normal 
mucosa.  Over  the  growth  the  normal  folds  disappear  and  the  surface 
of  the  lesion  is  irregular,  granular  or  nodular.  In  most  cases 
secretion  covers  the  site  of  the  growth.  The  growth  varies  in  color 
from  white  through  gray  and  yellow,  to  pink,  red,  crimson,  purple  or 
brown.  Malignant  disease  gives  the  best  picture  for  diagnostic  pur- 
poses when  the  growth  has  reached  the  fungus  stage. 

When  the  mucosa  is  infiltrated  but  unbroken  the  tube  can  he  used 
to  palpate  the  growth  and  to  determine  the  extent  of  the  infiltration. 
In  this  way  the  growth  may  be  pushed  up  to  the  abdominal  wall  and 
made  accessible  to  external  palpation.  The  sense  of  touch  transmitted 
through  the  tube  is  a  great  help  in  making  the  diagnosis  of  malignancy. 

Gastroptosis  and  Gastrectasia.  The  position  of  the  greater  curva- 
ture and  the  vertical  diameter  of  (lie  stomach  are  easily  obtained.  The 
position  of  the  pylorus  is  essential  in  order  to  distinguish  between  an 
enlarged  stomach  and  a  stomach  displaced  downward.  If  the  stomach 
is  of  the  infantile  variety  the  position  of  the  lesser  curvature  is  easy  to 
make  out,  otherwise  it  is  not. 


CHAPTER    VI. 
PLASTIC  SURGERY  OF  THE  NOSE  AND  EAR. 

By  .Joseph  (1.  Berk,  M.  I). 

General  Considerations. 

The  borderline  of  general  surgery  and  oto-Iaryngology  is  so  indis- 
tinct by  reason  of  the  evidence  furnished  by  the  study  of  this  subject 
that  there  is  some  question  as  to  where  it  rightfully  belongs.  It  is  the 
conviction  that  the  laryngologist  and  otologist  have  the  greater  claim 
that  impels  the  author  to  treat  this  subject  from  the  specialist's  stand- 
point. The  oto-laryngologic  surgeon  is  better  qualified  to  do  this 
work  simply  because  he  is  so  well  informed  on  the  requirements  of 
these  structures  from  their  anatomic  characteristics  and  their  physio- 
logic functions.  Cosmetic  considerations  do  not  constitute  the  sole 
reason  for  the  performance  of  these  operations. 

The  deformities  or  malformations  which  call  for  plastic  proced- 
ure may  be  real  or  imaginary.  The  latter  comprehend  slight  devia- 
tions from  the  normal,  very  much  exaggerated  by  the  individual,  on 
account  of  which  the  patient  becomes  the  patron  of  the  beauty  doctor. 
The  psychiatrist  would  be  of  more  service.  Only  real  deformities  or 
malformations  are  considered  in  this  chapter.  Kadi  case  is  a  law  unto 
itself  as  to  the  techuic,  yet  many  varieties  and  modifications  of  meth- 
ods must  be  described.  The  purpose  here  is  to  illustrate  rather  than 
to  give  extensive  descriptions  of  definite  methods. 

History. — Reconstructive  surgery  with  special  reference  to  rhino- 
plastic  operation  dates  back  to  the  publications  of  Tagliacozzi  in  l.")H7 
(Figs.  208  to  222)  although  earlier  reports  of  plastic  surgery  of  the 
face  were  said  to  have  been  made  by  Benedietiis  in  1492.  Tagliacozzi 's 
work,  however,  was  not  taken  up  very  enthusiastically  until  about  the 
eighteenth  century,  when  a  large  number  of  surgeons  recognized  the 
value  of  this  branch  of  surgery.  Since  then  important  contributions 
have  been  made  by  Rosenstein,  Dubois,  Boyer,  Carpeie,  (\  Uraefe, 
Balfour,  Zeis,  Biinger,  IFoffacker,  Warren.  Dieffenbadi.  Blandin,  Koux, 
Serre,  Jobert,  Mutter,  Post,  Pancoast,  Buck,  Andrews,  Prince,  Koberts, 
Koenig,  Israel,  Joseph,  Langenbeck,  Oilier,  Xelaton,  Keegan.  Hoe, 

(279) 


280  OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 


Fig.  208. 


Fig.  209. 


Illustrations  from  Tauliaoozzi'K  work. 


PLASTIC    SUKCKKV    <)!•'    TI1K     NOSK    AM)     KAK. 


Smith,  Kolle,  Beverdin,  Wolfe,  Krausc,  Thiersch,  (Jcrsiiny,  Lexer,  Carl 
Beck  and  many  others. 

Indications. — In  considering  the  indications  for  plastic  surgery  of 
the  nose  and  the  ear,  we  have  in  mind  the  correction  of  defects;  first 
for  the  re-establishment  of  certain  functions,  such  as  respiration,  phona- 


Fig.  21' 


Fig.  218. 


Fig.  219. 


Fig.   220.  Fig.   221.  Fig.   222. 

Appliances   and    instruments    employed    by    Tag'liacoz/i. 

tion,  deglutition,  audition;  and  secondly  for  cosmetic  requirements. 
Of  these  the  former  purpose  is  by  far  the  most  important  from  the 
operator's  point  of  view,  but  the  latter  is  often  of  greater  interest  from 
that  of  the  patient.  At  the  same  time  the  cosmetic  indication  must  not  be 
undervalued,  as  by  reason  of  deformities  and  malformations  many  un- 
fortunate individuals  are  denied  equal  chances  and  privileges  in  life 


282  OPERATIVE    SURGERY    OF    THE    NOSE,,    THROAT,    AND    EAR. 

with  their  fellow  man.  It  can  bo  stated  unhesitatingly  that  even  when 
the  best  results  are  obtained  cosmetically,  the  patients  are  still  much 
handicapped  by  their  appearance,  since  such  results  still  leave  them 
objects  of  curiosity  and  comment.  This  of  course  is  more  especially 
true  of  extreme  deformities  of  the  rose  and  ear. 

The  so-called  better  classes  are  annoyed  by  certain  minor  deformi- 
ties, malformations  and  blemishes  which  injure  their  pride,  but  which 
otherwise  are  of  little  consequence.  However  good  a  result  is  achieved 
by  the  operation,  the  patients  are  never  entirely  satisfied,  and  persist 
in  their  desire  to  have  more  work  done.  These  unfortunates  mostly 
self-centered  and  neurotic  individuals  become  the  prey  of  the  so-called 
" beauty  doctor,"  and  many  bad  consequences  result  from  the  unscien- 
tific surgery  of  the  latter. 

It  is  best  to  attempt  to  discourage  them  from  having  plastic  opera- 
tions performed;  furthermore,  great  care  should  be  exercised  when 
operating  on  them  to  have  the  patients  or  their  immediate  family  as- 
sume all  the  responsibility  as  to  the  cosmetic  results. 

As  a  preliminary  to  the  performance  of  plastic  surgery  it  is  nec- 
essary in  order  to  obtain  the  best  results  to  ascertain  whether  or  not 
some  general  or  local  pathologic  condition,  such  as  lues,  tuberculosis, 
general  anemia,  malnutrition  is  present.  These  are  among  the  most 
frequent  causes  of  failure.  A  local  chronic  skin  infection,  as  ec/ema 
or  granuloma,  will  retard  or  prevent  healing  even  if  the  plastic  has 
been  perfect. 

Important  Factors. — Since  there  are  so  many  varieties  of  deform- 
ities there  are  naturally  a  great  many  procedures  for  their  correction. 
After  all  it  remains  for  the  individual  operator  to  use  his  judgment  as 
to  the  selection  of  a  particular  type.  Again,  frequently  a  plan  must  be 
changed  during  the  operation  and  an  entirely  different  principle  ap- 
plied, or  perhaps  a  combination  of  different  principles  or  operations 
must  be  adopted. 

It  is  of  great  help  to  know  the  condition  and  position  of  the  struc- 
tures previous  to  the  deformity.  If  this  has  existed  from  birth,  the 
normal  condition  of  the  parts  should  be  known.  This  is  especially  im- 
portant in  nasal  and  ear  plastics.  For  instance,  in  constructing  a  nose, 
the  surgeon  is  very  fortunate  if  he  can  obtain  a  photograph  taken  be- 
fore the  deformity  was  acquired.  Sometimes  photographs  of  the 
closest  relative  who  is  known  to  have  resembled  the  patient  before  in- 
jury, arc  of  u'reat  service.  To  make  a  nose  of  the  Roman  style  when, 
as  a  matter  of  fact,  the  patient  had  a  short  stubby,  thin,  straight  or 
bulbous  nose  before,  would  he  ignoring  an  important  principle. 


PLASTIC    SrU<;KKY     OF    T 1 1  K     NOSK    AND     KAH. 


In  ear  plastic  the  opposite  ear  inny  be  used  as  a  model,  in  the  ma- 
jority of  instances. 

The  selection  of  the  method  of  operative  procedure  is  naturally  of 
great  importance.  A  definite  rule  cannot  always  he  laid  down  since, 
as  has  been  said,  each  case  is  a  law  unto  itself,  and  the  operation  indi- 
cated varies  with  the  age,  condition,  and  vocation  of  the  patient.  A 
rule  which  the  writer  has  followed  is  to  employ  at  first  a  method  in- 
volving no  loss  of  tissue,  and  consequently  no  additional  deformity  in 
case  of  failure.  In  other  words,  it  is  best  to  form  the  nasal  structure 
by  employing  transplantation  methods  in  preference  to  using  flaps 
from  the  face  or  forehead.  Similarly  intranasal  are  to  be  preferred 
to  external  methods. 

Flaps  should  be  properly  selected  and  prepared.  They  should  be 
measured  out  previous  to  the  operation,  one-third  larger  than  the  de- 
fect, and  made  very  plastic,  that  is,  with  not  too  much  underlying 
tissue.  Making  them  too  thin  or  devoid  of  subcutaneous  tissue  is  even 
a  greater  mistake,  since  their  nourishment  is  thus  likely  to  be  affected. 
It  is  necessary  to  make  their  pedicles  conform  to  the  blood  supply; 
that  is,  to  construct  the  flaps  so  that  the  greater  diameter  of  the  vessel 
is  in  the  pedicle  and  not  in  the  periphery.  If  the  pedicle  is  too  greatly 
twisted  strangulation  of  the  flaps  may  occur. 

While  perfect  cleanliness  or  asepsis  is  practically  impossible  in 
nasal  surgery,  great  care  should  be  taken  not  to  introduce  foreign 
microorganisms  into  the  wound. 

Thorough  removal  of  diseased  tissues  as  well  as  of  cicatrices  is 
quite  as  important  as  the  free  undermining  of  the  borders  of  the  wound. 
Patches  of  skin  or  mucous  membrane  must  be  dissected  out,  since  the 
retention  of  nests  and  the  accumulation  of  epithelium  may  prevent  a 
good  result. 

Covering1  Defects. — It  is  advisable  to  study  the  principles  which 
govern  the  covering  of  congenital  or  created  defects.  Dieffenbaeh, 
Langenbeck  and  others  have  developed  this  subject  to  such  an  extent 
that  almost  any  form  and  size  of  defect  in  the  skin  may  be  covered  with- 
out causing  a  marked  deformity  in  the  region  from  which  the  tissues 
are  taken. 

1.  Defect*  may  be  covered  by  making  incisions  in  certain  direc- 
tions and  uniting  in  the  opposite  direction,  thus  loosening  the  tissues 
and  uniting  them  in  the  best  possible  manner  so  that  the  tension  is  the 
slightest.  Counter-incisions,  to  relax  the  tissues  and  to  facilitate  easy 
approximation  of  the  skin,  are  also  frequently  employed.  Fig.  '2'2'.l 
demonstrates  various  shaped  defects  and  the  method  of  covering  them. 
The  arrows  indicate  the  direction  in  which  the  flaps  should  be  turned. 


284 


OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 


'2.     Skin    Graft 'nif/. — A,   Reverdin;    B,     Thiersch;     C,    Wolfe    or 
Krause;  I),  Epithelial  spread. 

(A)     The  Reverdin  method  is  to  raise  a  small  bit  of  epidermis 


\ 


Incisions   and    flaps    for    closing    defects.      (Cclsus.) 


PLASTIC,    SrUCKIJV    OK    T 1 1  K     NOSK    AND     KAI{. 


L'8f> 


by  means  of  a  noodle,  snip  it  off  with  knife  or  scissors  and  place  it  over 
the  prepared  granulating  surface.    (Figs.  '2'24  and  ±_T). ) 

(B)  Thiersch  grafts  are  obtained  either  from  the  arm  or  leg 
(from  parts  containing  little  hair)  by  placing  the  skin  on  a  stretch  and 
employing  a  very  keen  razor  or  special  knife.  (  Fig.  ±_'(i.)  With  a  steady 
side  to  side  movement,  the  epidermal  layer  is  cut  off  and  folded  on  the 
knife.  .By  means  of  this  knife;  the  graft  is  carried  over  to  the  granu- 
lating area  to  be  covered,  and  by  the  aid  of  a  needle  it  is  laid  and  spread 
out  on  the  defect.  Particular  attention  is  paid  to  the  margins  of  the 
graft,  so  that  they  are  thoroughly  spread  out,  and  not  rolled  in.  This 
should  bo  done  as  carefully  as  when  preparing  a  microscopic  specimen. 
The  next  graft  should  not  be  applied  too  close  to  the  first,  and  so  on, 


Fig.  224. 
Making   Hevcrdin   graft. 


Fig.  225. 
Kovcrdin  graft   applied. 


since  the  epidermis  grows  quite  readily  from  the  margins  and  thus 
bridges  over  more  easily  than  when  the  grafts  are  placed  too  close  to 
one  another.  The  grafts  should  not  lie  too  large,  since  these  do  not 
survive  as  well  as  small  ones.  After  the  entire  defect  is  covered,  the 
grafts  are  held  to  the  granulating  surface  by  means  either  of  strips  of 
paraffin  or  of  rubber  tissue  in  the  form  of  lattice  work. 

(C)  Wolfe  or  Kranse  grafts  are  transplantations  of  the  entire 
skin,  that  is,  of  epithelium  and  corium.  These  should  be  devoid  of 
very  much  subcutaneous  fat  and  should  not  be  too  large,  since  their 
vitality  is  much  interfered  with  when  they  are  of  more  than  one-half 
inch  in  size.  These  particles  of  skin  may  contain  hair  where  such  is 
required,  as  for  the  formation  of  eyebrows  or  on  the  upper  lip  in  the 
male,  to  form  a  mustache. 


286 


OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 


(]))  Epithelial  (Anssaht)  Spread.  By  means  of  a  razor  the  sur- 
face epithelium  is  scraped  until  a  slight  oozing  of  serum  (but  not 
blood)  occurs,  and  then  this  scraped  oft'  epithelium  is  smeared  on  the 
granulating  surfaces  in  a  very  thin  layer.  It  is  best  covered  with  a 
thin  layer  of  paraffin  before  covering  with  gauze  and  bandage. 

Recording  Cases  Before,  During  and  After  Correction. — As  has 
been  stated  it  is  best  in  all  cases  to  obtain  a  photograph  of 
a  patient  before  the  occurrence  of  the  deformity.  This  will  give  the 


Making   and   applying   Thicrsch   f^ral'l. 

operator  the  advantage  of  reproducing  as  nearly  as  possible  tbe  orig- 
inal condition  of  the  parts.  If  no  photograph  is  obtainable  or  if  there 
be  a  congenital  defect,  the  operator  will  be  called  upon  to  use  his  judg- 
ment in  the  reconstruction.  This  should  be  in  conformity  with  the 
rest  of  the  features  and  facial  expression.  It  is  necessary  to  know  that 
a  broad  face,  which  is  known  as  the  eurygnathous  variety,  will  require 


PLASTIC    SUHOERY    OF    THE    NOSE    AND    EAR. 


28; 


a  formation  or  reconstruction  of  a  broader  nose  than  it'  tin-  face  is 
protruding,  or  of  the  prognathous  type.  Again,  if  the  face  lie  of  the 
non-protruding  variety,  orthognathous,  a  short  nose  is  best  suited  to 
it.  (Roe.) 

The  next  step  is  to  obtain  a  very  detailed  history  and  to  make  a 
thorough  local  and  general  examination.  Tntranasal  and  pharyngeal 
inflammatory  and  obstructing  conditions  must  be  noted  as  well  as  the 
local  pathologic  changes  that  may  be  present  on  the  external  nose  or 
ear.  As  to  the  general  conditions  existing,  syphilis,  tuberculosis,  severe 
anemia,  and  malnutrition  must  receive  the  strictest  recognition. 


Fig.  227. 
Stereoscopic  photograph  of  plaster  cast. 

A  number  of  photographs  from  every  angle  should  be  taken.  The 
author  is  now  accustomed  to  take  stereoscopic  photographs,  which  are 
a  vast  improvement  over  the  single  exposure,  since  they  bring  out  much 
more  clearly  the  various  defects,  however  small  they  may  be. 

Plaster  casts  (Fig.  227)  are  excellent  positive  records  of 
the  condition  present.  The  following  inethod  is  used  for  making  casts: 
Fill  a  one-half  pint  bowl  half  full  with  tepid  water  and  plaster  of  Paris 
(dental)  until  the  latter  is  submerged.  Pour  off  excess  water  and  stir 
to  proper  consistency.  When  one  desires  quick  setting  of  the  plaster, 
a  pinch  of  table  salt  is  introduced  into  the  warm  water  before  the  plas- 
ter is  added.  Before  applying  it  to  the  face  a  fine  layer  of  vaselin  is 
spread  upon  the  skin  and  the  anterior  nares  or  the  nasal  apertures  are 
plugged  loosely  with  cotton.  A  small  rubber  tube  is  kept  ready  to 


288  OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 

place  into  the  patient's  mouth  at  the  last  moment,  just  before  the  plas- 
ter is  put  over  the  mouth,  in  order  that  the  patient  may  breathe  while 
the  plaster  hardens.  The  mask  is  begun  by  placing  the  plaster  in  thin 
layers  about  the  forehead  over  the  closed  eyelids,  cheeks,  lower  jaw, 
nose,  upper  lip,  lower  lip,  and  closely  about  the  tube.  This  first  layer 
is  reenforced  with  a  goodly  quantity  of  plaster  and  the  mask  is  allowed 
to  harden.  The  subject  should  avoid  any  facial  movements,  in  fact  he 
should  lie  perfectly  still  until  the  plaster  is  set,  which  takes  usually 
from  three  to  five  minutes  after  the  mask  is  finished. 

The  removal  of  the  formed  mask  is  now  very  carefully  manipu- 
lated so  that  it  may  come  off  in  toto.  If  it  should  unfortunately  break 
into  two  or  more  parts,  it  is  carefully  placed  together  and  cemented, 
as  is  done  by  the  dentist  in  making  plaster  casts.  In  fact  this  whole 
procedure  is  so  much  like  the  making  of  dental  impressions  that  the 
author  would  recommend  that  a  dentist  be  employed  for  the  purpose. 
To  make  the  positive  from  this  mask  is  the  next  procedure,  and  this  is 
accomplished  by  painting  the  inner  surface  of  the  thoroughly  dried 
cast  (mask)  with  separating  fluid  and  pouring  into  it  plaster  of  Paris 
until  it  is  thoroughly  filled.  This  is  now  allowed  to  harden  and  dry, 
when  the  mask  is  carefully  picked  off  from  the  positive  at  the  pink 
line  of  demarcation  of  the  fluid.  The  chips  and  defects  on  the  positive 
cast,  caused  by  this  tedious  process  of  picking  off  the  mask,  must  be 
repaired  with  plaster. 

Secondary  casts  and  photographs,  showing  the  effect  of  treat- 
ment, are  of  service  as  additional  records,  while  stereoscopic  photo- 
graphs are  even  better  than  plaster  casts. 

Rhinoplasty. 

Classification  of  Nasal  Deformities. 
L     ACCORDING  TO  ROK  : 

Deformities 


Bony  portion  Cartilaginous  portion 


Vertical  Lateral  Tip  Wings 


I  I  I  I 

Convex       Concave     Spatulated     Deflected 


Collapsed         Expanded 


Kxcessive  Deflection  from 

deficient  tissue  median  line 


PLASTIC    SUR(!EKY    OF    TJIK    NOSK    AND    KAK.  'JSJf 

II.     ACCORDING  TO  KOLLK.     (In  deficiencies    particularly    referable 
to  paraffin  injections.) 

/ 

Superior  one  t  hird. 
Middle  one-third. 

I.  Anterior  Nasal  Deficiency.  .  [  Inferior  one-third. 

j  Superior  one-half. 
I    Inferior  one-halt'. 

V  Total. 

TOTAL. 

„.  .  I  Unilateral. 

J.     Lateral  Insufficiency.,  -r,.. 

(  Bilateral. 

3.  Lo1)iilar  Insufficiency. 

4.  Interlobular  Insufficiency. 

v ,       7x   n  •  \  Unilateral. 

o.     Alar  Deficiency 

I  Bilateral. 

r  ,,   ,.  .  (Partial. 

().     feubseptal  Denciency \ 

( Complete. 

ITT.     Author's  Classification. 

A.  Etiology. — Traumatic;  Luetic;  Congenital ;  Tubercular  and  Lu- 
pus; Simple  infections,  as  abscess;  Periehondritic;  Atheromatous,  or 
Acne  Rosacea;  Neoplasms,  malignant  and  benign;  Gross  Imagination, 
or  Vanity. 

/>.    Form. 

1.     Large  hump  nose. 
'2.     Twisted  nose. 

3.  Kinked  and  double  kinked. 

4.  Saddleback,  kinked  and  with  wide  a  he. 

5.  Pinched  pointed,  with  collapsed  ahv. 

(>.  Flat  or  squashed,  with  large  ahv  and  large  vestibules. 

7.  Notched. 

8.  Congenital  absence   of  premaxilla   and   columellar  cartilage. 

9.  Pushed-in  nose. 

10.     Absence  of  external  nose  and  septum. 

II.  Unilateral  deformities. 
\'2.     Hare-lip  nose. 

13.  Combination  of  nasal  and  face  deformities. 

14.  Pound  or  hypertrophic  nose. 


290  OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 

Methods  of  Procedures  in  Nasal  Deformities  and  Malformations.— 

I.  German  or  French  method,  including  skin  grafting. 

II.  Italian  or  Tagliacozzi 's  method,  with  modifications. 

III.  Hindoo  or  Indian  method. 

IV.  Double  transplantation  method   (toe  to  hand,  to  nose). 
V.  Finger  method. 

VI.  Clavicle  method. 

VII.  Implantation  method  (paraffin,  tic.). 

VIII.  Reduction  method. 

IX.  Artificial  method. 

X.  Orthopedic  method    (Carter's  clam]),  pins,  etc.). 

XL  Intranasal  method. 

XII.  Miscellaneous  and  combination  methods. 

I.     German  or  French  Method.     (Facial.) 

AVhen  a  subtotal  destruction  or  an  unilateral  defect  is  to  be  cor- 
rected this  method  gives  excellent  results.  The  transposition  of  the 
newly-formed  parts  may  be  accomplished  by  sliding  or  pedicle  forma- 
tion. Small  defects  may  be  covered  by  real-ranging  flaps  from  the 
nose  itself  as  shown  in  Figs.  i2.'!4  and  '2'.}'). 

The  nasolabial  fold  offers  the  best  place  for  pedicle  flaps.  Flaps 
for  building  up  the  prominence  of  a  nose  as  well  as  for  forming  an  epi- 
dermal lining  of  the  nose  are  frequently  formed  from  the  cheeks  and 
turned  outside  in,  as  shown  in  Figs.  2JS  and  1'L'D.  Columella1  may  be 
made  from  the  point  of  the  nose,  from  the  outer  part  of  the  middle  of 
the  lip,  or  from  the  mucous  membrane  of  the  lips,  and  passed  through 
in  buttonhole  fashion,  as  shown  in  Fi.u's.  I'ol'-l'b'O.  It  is  most  impor- 
tant to  loosen  the  parts  thoroughly  and  to  effect  perfect  adaptation 
of  the  margins.  Portions  of  the  nasal  bones,  nasal  processes  of  the 
superior  maxilla  or  of  the  premaxilla  and  the  floor  of  the  nose,  are 
utilized  for  support  of  the  nose  formed  after  this  method.  (Figs.  'JSll! 
and  1_'S7.)  Other  materials  for  support  are  cartilage  from  the  septum 
resected  from  other  patients,  or,  clavicle,  and  bones  from  the  toes, 
'infers,  and  the  anterior  surface  of  the  tibia.  (  Figs.  .'107-.'!  14.) 


PLASTIC    SCKCKHV    OK    T 1 1  K     NOSK    AND    KAU.  21)1 

CoKHKCTION   OK    I' N  I  LATKUAL  A  N  D   I>AI{'MAL   I  )  KI-  ICI  K  N(  'I  KS  OK  TIIK   \OSK. 

Legg's  Operation. 

1.  Make  a  small  tongue-shaped  Ha}),  with  its  hinge  pedicle  at  the 
nasolabial  crease.    (Fig.  22S.) 

2.  Turn  over  with  skin  surface  into  the  vestibule,  and  suture  all 
about  the  margins  of  the  ala,  which  have  been  freshened  up,  and  close 
created  defect  on  the  cheek.      (Fin1.  22!).) 


Fig.   228.  Fi.i;.   22<». 

Lc.Uii's  operation   for  correction  of  unilateral  and  partial   deficiencies  of    the  nose. 

Out'    \Vrrlc  Litter. 

.">.  Sever  the  pedicle  and  readjust,  then  suture  to  the  remaining 
alar  margins. 

4.     Cover  the  (lap  with  a  thin  Thiersch  uraft. 

Koenig's  Operation. 

1.  Make  a  seniilunar  incision  through  the  ala  remaining  and  dis- 
sect the  margin  away.  (Fig.  :2-')().) 

'2.  Take  a  Wolt'e  graft  fi'oni  the  thick  skin  of  the  back  of  the 
neck  and  implant  into  the  alar  defect.  (Fig.  l2.''>1.) 

Von  Esmarch's  Operation. 

1.     Make  a  Hap  in  the  nasolabial  fold.    (Fig.  I'.'!-!.) 
L'.     Turn    on    its    pedicle    with    the    skin    outwards    and     suture. 
(Fig.  2:5:?.) 

.'}.      Eventually  sever  the  pedicle  one  week  later  and  readjust  parts. 


292  OPERATIVE    SURCERY    OF    THE    NOSE,    THROAT,    AND    EAR. 


Fig.  230.  Fig.  231. 

Koenig's  operation. 


Fig.  232.  Fig.  233. 

Vim  Ksinaivli's  operation. 


Fig.   2::4. 


Fig.   2:',f>. 


Von  Laiitfonboek's  operation. 


PLASTIC    Sl'KCKKY    OF    TJ-IK    NOSH    AND    KAK. 


Von  Langenbeck's  Operation. 

1.     Freshen  up  the  surfaces  on  the  defect. 

'2.      Make  a  Hap  on  the  healthy  side  of  the  nose  wit  h  the  pedicle  over 
the  side  of  the  defect.    (Fig.  234.) 

3.  Dissect  this  Hap   loose  and   stitch   into    the    prepared    defect, 
turning  in  the  lower  margin  of  the  Map  so  as  to  make  the  nostril  have 
a  dermal  surface.    (  Fig.  235.) 

4.  ("over  the  newly-formed  defect  either  with  skin  graft  or  dis- 
sect loose  the  tissue  of  the  cheeks  and  cover  the  defect  by  sliding  the 
skin  over  it. 


Fig.  236.  Fig.  237. 

Dieffenbach's   operation. 


Fig.  238. 
Von  Esmarch's  operation. 


Dieffenbach's  Operation. 

1.  Make  a  reversed  V-shaped  incision  through  the  a  la  above  the 
defect  and  dissect  freely.  (Fig.  23(i.) 

'2.     Reunite  in  the  form  of  three  three-cornered  Maps.    (Fig.  237.) 

Von  Esmarch's  Operation. 

1.     Freshen  up  the  margins  of  the  defect 

'2.  Make  a  Map  of  the  side  of  the  cheek  with  a  pedicle  on  the  side  of 
the  nose.  (Fig.  238.) 

3.     Implant  flap  and  suture  on  three  sides. 

One  Week  Later. 

•4.  Sever  the  pedicle  and  complete  the  closure  of  the  defect  on 
the  ala  as  well  as  of  the  newly-formed  defect  on  the  side  of  the  nose  and 
cheek.  (Fig.  23S.) 


2D4 


OPERATIVE    STKdEKV    OF    THE    XOSE,    THROAT,    AND    EAR. 


Busch's  Operation  for  Partial  Loss  of  Tip  and  One  Side  of  the  Nose. 

1.  Form  a  lateral  flap.  The  pedicle  is  formed  on  the  side  of  the 
cheek  opposite  to  the  defect  of  the  ala,  and  the  main  body  of  the  flap 
is  made  from  the  bridge  of  the  nose.  (Fig.  239.) 

'2.     Remove  the  undesirable  skin  margin  of  defect. 

,'>.  Dissect  the  flap  and  suture  in  position,  the  prominent  convex 
border  of  the  flap  being  fitted  well  into  outer  margin  of  the  defect. 
The  tongue-shaped  portion  makes  a  well-adjusted  tip  and  columelhr 
covering. 

4.  The  newly-formed  defect  is  covered  and  corrected  one  or  two 
weeks  later,  when  the  pedicle  is  severed. 


Busch's    operation    for    partial    loss    of    tip    and    one    side    of    nose. 

Nelaton's  Operation. 

1.  Form   two  quadrangular   flaps    from   the  cheeks,   the   bases   of 
which   are  situated   over  the   bridge  of  the  nose  and  angle  of  the  eye. 
One  of  the   flaps  should    have   an   additional   central    Map   to   form   the 
columella.    (  Fig.  240.) 

2.  Freshen  the  margins  of  the  defect. 

.'!.  Bring  flaps  together  and  suture  in  place  over  the  iiltrum  of 
the  columella. 

4.  Cover  created  defect  either  by  \Volfe  or  Thiersch  grafts,  or 
slide  over  the  skin  from  the  cheek's. 


PLASTIC    Sl'HIiKRV    OK    THK    NOSK    AND    KAR.  290 

Syme's  Operation. 

1.  Two  lateral  flaps  are  made,  one  to  each   side    of    the    defect, 
extending  to  the   lateral   portion  of  the   nose  and   to  the  cheeks,  both 
these  Haps  having  a  common  central  pedicle  over  the  root  of  the  nose. 
(Fiii-.  241.) 

2.  Freshen  up  the  margins  of  the  nasal  defect. 

.'>.     Suture  the  two  flaps  together  in  the  median  line. 

4.     Turn  the  skin  in  at  the  lower  margins  of  the  flap,  and  suture 


Fig.  240. 
Nelaton's  operation. 

so  as  to  make  a  cutaneous  surface  where  the  nostrils  will  subsequently 
be  formed.     (Fig.  242.) 

5.  Suture  the  two  lateral  flaps  into  the  raw  surface  on  the  side 
of  the  nose. 

6.  Dissect  the  skin  of  the  cheek  and  bring-  it  close  to  the  lateral 
flaps  and  suture.    Any  defect  remaining  may  be  covered  by  skin  grafts 
or  be  allowed  to  granulate. 

7.  Tubes  of  stiff  rubber  are  placed  in  each  primitive  nostril. 

8.  Subsequent  formation  of  the  columella  from  the  upper  lip. 

CORRECTION  OF  TOTAL  Loss. 

Helferich's  Operation  (French  Method). 

1.  Make  a  quadrangular  flap  from  one  side  of  the  cheek  with  its 
pedicle  on  the  side  of  the  nose,  for  the  purpose  of  support  and  to  line 
the  nose  with  skin.  (Fig.  243.) 


L'96  OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 


opcrat  ion. 


PLASTIC  SI;J{I;KUY  OK  TMK   NOSH  AND  HAH. 


297 


Fig.  244. 
Helferich's  operation   for  total  loss  of  nose. 


298  OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 

2.  Make  a   somewhat  oblong  flap  from  the  other  clieek  with  its 
pedicle  placed  towards  the  inner  corner  of  the  eye,  for  the  purpose  of 
covering  the  first  Hap,  and  reconstruct  the  nose.    (Fiji,1.  '24'.}.) 

3.  Dissect  and  turn  the  quadrangular  Ha])  across  the  nasal  defect, 
and  suture  the  previously  freshened  margins  of  the  nasal  defect,  fac- 
ing its  skin  surface  into  nasal  cavity.    (Fig.  244.) 

4.  Dissect  oniony  Hap  and  bring  it  in  contact  with  the  denuded 
surface  of  the  Hrst  Ha]>,  and  suture  in  place. 

f).  Close,  by  sliding  and  readapting  the  skin  about  the  cheeks 
over  the  newly-formed  defects. 

One  Wcrl-  Later. 

6.  Sever  pedicles  and  readapt  the  parts  to  a  smoother  healing 
surface;  secondary  operation  upon  the  ahv  and  columella. 

Roberts'  Operation  for  Sunken  Bridge  With  Upturned  Lobule  or  Tip 
of  Nose.     Fie.  24."). 

1.  A  transverse  incision  is  made  into  the  nasal  cavity,  the  tip  of 
the  nose  being  pulled  down  so  that  the    nostrils    appear    horizontal. 
(Fig.  246.) 

2.  An  inverted  V-shaped  incision  is  made  between  the  eyes  up  to 
the  forehead.    (Fig.  24f>.) 

.'5.  The  skin  and  subcutaneous  tissue  between  the  first  transverse 
and  the  second  V  incision  are  dissected  thoroughly. 

4.  This  dissected  skin  is  brought  down,  the  point  of  the  (lap  dis- 
placed as  low  as  possible,  and  the  lower  defect  broadly  sutured.  (Fig. 
247.)  This  forms  a  good  prominence  over  the  former  depression. 
Dressing  should  be  retentive  so  far  as  to  hold  the  tip  of  the  nose  down. 

Roberts'  Operation  for  Sunken  Saddle-back  Nose. 

1.  Sever  the   lobule  and   ala>   from   their  bony   and   cartilaginous 
attachments  at   the  deepest   part   of  the  saddle. 

2.  Draw  the  lobule  and  alai  down  so  as  to  bring  the  nostrils  into 
an  almost  horizontal  plane;  this  leaves  a  conical  defect  into  the  nasal 
cavity.    (Fig.  24S.) 

.'!.  Make  two  small  skin  (laps  from  the  cheeks  with  their  pedicle 
towards  the  root  of  the  nose.  (Fig.  24S.) 

4.  When  these  flaps  are  dissected,  they  arc  turned  with  their  epi- 
dermal surfaces  towards  the  nasal  cavity  and  are  united  one  to  the 
other  as  well  as  to  the  upper  portion  of  the  newly-formed  defect  in 
the  nose.  'Phis  brings  their  raw  surfaces  externally  for  granulation 
formation  and  subsequent  support  for  the  newly-formed  skin  (laps 


PLASTIC    StTH<;KKY    (»K    Tl  I K     NOSK    AM)    KAK. 


299 


Fig.   245. 


Fig.  246.  Fig.  247. 

Robert's  operation   for  sunken   bridge   with   upturned   lobule  or   tip   of  nose. 


IJOO  Ol'KRATIYK    SUKtiKKY    OF    THE    NOSE,    THROAT,    AND    EAR. 


Fig.  249. 


Robert's   opcraliun    for  suiikdi    saddle-back    nose. 


I'LASTIC    Sl'KCKUY    OK    TIIK     NOSH    AND    KAU. 

The  defects  in  the  cheeks  create*!  by  tliese  flaps  are  at.  once  united. 
(Fig.  249.) 

5.  About  one  week  to  ten  days  later,  the  irregularities  about  tin- 
base  of  tliese  check  flaps  are  corrected  by  incisions  and  proper  sutures 
so  as  to  obtain  a  smooth  surface. 

(>.  When  all  the  inflammatory  reaction  has  disappeared,  usually 
in  about  three  to  four  weeks,  an  inverted  V-shaped  incision  is  made 
down  to  the  bone.  Corresponding  to  this  incision  just  above  the  mar- 
gin of  the  nasal  defect,  which  is  now  covered  by  the  inverted  skin  flaps, 
a  similar  incision  is  made  except  that  the  legs  of  the  V  run  more  hori- 
zontally. While  the  legs  of  the  upper  incision  terminate  below  the 
eyes,  close  to  the  inner  corner,  the  lower  come  out  further  on  the  cheeks, 
giving  greater  plasticity  to  the  flaps.  The  apices  of  the  two  inverted 
V-shaped  incisions  are  now  joined  by  a  vertical  one  immediately  over 
the  crest  of  the  nose.  (Fig.  250.) 

7.  These  two  flaps,  rhomboid  in  form,  are  dissected  very  freely 
from  the  underlying  tissues  and  the  cicatrized  surface  of  the  skin  flaps 
covering  the  defect  freshened  by  gently  scraping  with  the  knife  blade. 
One  flap  is  turned  so  as  to  fit  its  extreme  point  or  tip  into  the  opposite 
extreme  point  of  the  defect  and  is  anchored  by  a  suture;  then  the  sec- 
ond flay)  is  brought  above  the  first  so  as  to  fill  in  the  defect  to  the  great- 
est extent,  and  is  anchored.  This  will  leave  a  somewhat  triangular 
defect  at  the  root  of  the  nose  and  lower  portion  of  the  forehead  which 
is  closed  by  three  or  more  sutures  in  a  vertical  line.  The  two  flaps  are 
now  sutured  to  the  various  margins  and  to  themselves  as  shown  in 
Fig.  251. 

FORMATION  OF  A  XKW  COLTMKLLA   (Fuo.M  THI-:  FPPKH  LIP). 
Dieffenbach's  Operation. 

1.  Two  parallel   incisions,   separated   about  one-fourth  inch,   are 
made  through  the  entire  thickness    of   the   upper    lip  up  to  the  margin 
of  the  nasal  floor.    (Fig.  252.) 

2.  Turn  this  tongue-shaped  flap  so  that  the   skin   surface   looks 
into  the  nasal  cavity  and  mucous  membrane  externally,  and  locate  a 
point  where  the  free  end  of  this  flap  will  touch  the  nasal  tip  without 
undue  tension  or  twist  of  the  base  of  the  flap. 

:>.     Denude  this  located  area  of  skin.    (Fig.  252.) 

4.  Remove  the  mucous   membrane   from   the   tip   of  the   tongue- 
shaped  flap. 

5.  Suture  this  tip  into  denuded  surface  of  nasal  tip.    (Fig.  25:5.) 

().  Liberate  the  margins  of  the  newly-formed  defect  in  the  inid- 
dle  of  the  lip. 


OPERATIVE    STRiiEHV    OF    THE    NOSE,    THROAT,    AND    EAR. 


7.     Suture  skin  and  mucous  membrane  separately.    (Fi.u;.  l25.'x) 
S.     If  the  operation  is  on  a  man,  it  may  be  necessary  to  denude  the 
tongue-shaped  flap  of  its  dermal  covering  as  the    hair    \vould    subse- 
quently irritate  the  interior  of  the  nose. 


Fig.  252.  Fig.  253. 

Dieffenbach's  operation   for  formation  of  new  columella  from  the  upper    lip. 


Operation   for  formation  of  new  colnni"lla   from  the  dorsum   of  the  nose. 
I  1 1  indoo    im  t  hod. ) 

From  the  Dorsum  of  the  Nose  (Hindoo  Method). 

1.  An  oblong  flap  is  made,  the  pedicle  bein.u1  at  the  side  of  the  ah 
ni n in iiu'  to  the  tip  of  the  nose. 

'2.  A  defect  is  made  at  the  junction  of  the  upper  lip  with  floor  ol 
the  nose.  (  Fiir.  L).")4. ) 


PLASTIC    Sl'WiKUV    OF    T1IK     NOSH    AM)     KAK.  ',>()'.> 

M.     'I1  he  flap  is  turned  downward  and    sutured     into    this    defect. 

4.  The  defect  on  dorsuni  of  nose  is  sutured  or  a  skin  graft  is 
used. 

f).  Any  slight  irregularities  are  to  he  corrected  at  a  subsequent 
time  when  the  pedicle  is  severed. 


Fig:.  256. 


Fig.  257. 


Fie.  258. 


Fig.   259 


Fig.   260. 


Lexer's    operation    for    the    formation    of    columolla    from    the    mucous 
membrane  of  the  upper  lip. 

Lexer's  Operation  for  the  Formation  of  Columella  (from  the  Mucous 
Membrane  of  the  Upper  Lip). 

1.  Construct  a  tongue-shaped  flap  with  its  hase  towards  th" 
ii'iiiiuval  margin  on  the  under  surface  of  the  upper  lip,  made  up  of 
mucous  membrane  and  some  underlying1  submucous  tissue.  (Fig.  iMd.) 

1*.  Dissect  it  loose,  and  close  to  its  hase  remove  the  epithelial 
surface  of  a  small  transverse  strip  which  will  subsequently  he  within 
a  buttonhole  of  the  upper  lip.  (Fig.  l2-")7.) 

o.  Form  the  flap  in  a  sort  of  a  roll,  suturing  the  margins.  (  Fiu\ 
258.) 


304  OPERATIVE    SUROERY    OF    THE    NOSE,    THROAT,    AND    EAR. 


Fig.  261. 


Fit;.   2K1. 
Italian  or  Ta.^liarox/.i's   method. 


PLASTIC    SUHCEKY    OK    TIIK    NOSK    AND    KAH. 

4.  Make  a  buttonhole  in  the  center  at  the  junction  of  the  upper 
lip  and  floor  of  the  nose,  through  the  thickness  of  the  lip,  in  front  of 
the  pedicle  of  the  flap.  (Fig.  L.T)!).)  Also  make  a  notch  at  the  tip 
of  the  nose. 

f).  Bring  the  flap  through  and  suture  into  the  notch  at  the  tip  of 
the  nose  and  also  at  the  buttonhole.  (Fin1.  lM>0. ) 


Fig.  26;',. 
Italian   or   Tagliacozzi's  method. 


II.     Italian  or  Tagliacozzi's  Method. 

This  method,  which  is  the  oldest,  is  not  employed  to  any  great  ex- 
tent at  the  present  time,  as  the  patient  is  very  much  inconvenienced  by 
bavin,0,1  his  arm  held  in  a  very  constrained  position  for  such  a  lonir 


306  OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 

period.  Its  purpose  is  to  obtain  a  flap  from  the  arm  as  shown  in  Fig. 
261. 

1.  The  flap  may  be  allowed  to  become  firm  and  of  proper  size  by 
placing  rubber  tissue,  Cargile  membrane  or  anointed  gauze  between 
the  denuded  surface  so  as  to  prevent  it  from  reuniting.  The  flap  should 
always  be  made  one-third  larger  than  the  surface  to  be  covered  on  ac- 
count of  the  subsequent  shrinking. 

'2.  After  the  parts  about  the  nose  are  freshened  and  loosened  up 
the  flap  is  sutured  for  about  two-thirds  of  the  distance,  holding  the 
hand  over  the  top  of  the  head  and  fixing  it  by  means  of  adhesive  plas- 
ter as  in  Fig.  262.  The  pedicle  should  not  be  twisted  too  acutely. 

3.  A  complete  immobilization  plaster  cast  is  put  over  this  pri- 
mary adhesive  fixation,  care  being  taken  to  protect  the  eyes  while  it 
is  being  applied.  After  it  has  thoroughly  hardened,  spaces  or  win- 
dows are  cut  out  so  as  to  expose  the  wound,  the  eyes,  ears  and  month, 
as  in  Fig.  263.  The  wound  is  covered  by  a  separate  dressing.  This 
cast  is  allowed  to  remain  until  the  parts  have  healed,  the  stitches  be- 
ing removed  usually  in  one  week  to  ten  days.  It  is  then  time  to  sever 
the  attachment  of  pedicle  to  the  arm.  The  remaining  portion  of  the 
defect  about  the  nose  is  freshened  and  loosened  up,  the  pedicle  trimmed 
to  fit  the  parts,  making  allowance  for  a  columella,  and  the  external 
parts  of  the  nose  finished.  The  skin  defect  on  the  arm  is  cleansed, 
the  margins  are  freshened  and  loosened  up  and  sutured.  Grafts  may 
be  used,  or  the  defect  may  be  allowed  to  heal  by  granulation. 

Israel's  Operation. 

Instead  of  obtaining  the  flap  from  the  arm,  one  is  made  from  the 
forearm  and  the  arm  and  forearm  are  so  placed  as  to  make  the  patient 
most  comfortable,  as  shown  in  Fig.  2(54.  The  retention  of  the  arm  is  the 
same  as  in  the  Tagliacozzi  method. 

1.  Make  incision  in  left  forearm  symmetrically  on  both  sides  of 
the  ulnar  edge,  and  form  a  trapezoidal  skin  flap.   The  small  part  of  the 
trapezoid  which  points  towards  the  wrist  should   be  4.f)  cm.   from  the 
styloid  process.    (Fig.  265.) 

2.  With  a  chisel,  outline  a  bone  (la))  from  the  ulna  in  connection 
with  the  partially  dissected  skin  flap  0.75  cm.  wide  and  (!  cm.  long.    (Fig. 
265.) 

3.  With  a  fine  saw  this  hone  sliver  is  severed  from  the  ulna,  care 
being  taken  that  it   remains  attached  to  the  skin  flap  and  to  the  ulna 
at  the  upper  end.      lodoform  gauze  is  interposed   to   prevent    reunion. 


A   Fete  Daifs  L<ili'i\ 

4.      Break  the  hone  bridge  at  the  point  where  the  tip  of  the  nose  is 


PLASTIC    SURGERY    OF    THE    NOSE    AND    KAK. 

to  be  formed  and  dress  in  this  form.     Allow  for  greater  thickening  of 
parts  for  another  three  to  four  days. 

5.     Transplant  flap  to  nasal  defect  and  fix  at  the  side  as  shown 
in  Fig.  l2()4.   Immobilize  by  the  usual  method  of  plaster  of  Paris  jacket. 


Fig.  264. 


Fig.  265. 
Israel's  operation. 

Tico  Weeks  Later. 

6.  Sever  the  bony  and  skin  pedicle  and  readjust  parts  to  form  a 
nose.     The  bone  should  be  united  with  the  nasal  spine  at  the  floor  of 
the  nose  and  the  skin  sutured  about  the  side  of  the  nose. 

7.  Form  the  columella  and  nostril  from  the  remaining  skin  flap 
that  was  purposely  taken  for  their  formation. 


SOS 


OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 


Dieffenbach's  Operation. 

1.  Outline  a  trapezoidal  flap  above  the  elbow  on  the  inner  sur- 
face, one-third  larger  than  the  newly-formed  nose  is  to  be. 

2.  The  heavy  lines  in  Fig.  266  show  the  formation  of  incisions 
and  this  skin  flap  is  dissected  freely. 

o.     Turn  in  one-half  of  this  flap  so  as  to  bring  the  skin  next  to  the 


Fig.  - 
DiotTciihach's  operation. 


raw  surface  of  t  lie  arm  in  order  to  prevent  adhesion  and  also  to  form  the 
so-called  roll  of  the  dorsimi  of  the  future  nose;  fasten  by  two  sutures. 
(Fig.  207.) 

S/. I'  \Vi'd:s  Later. 

4.  Sever  the  upper  part  of  the  Hap  and  turn  downward.  Remove 
the  two  stitches  and  lay  the  (hip  open  partially.  (  Fig.  2(5^.) 

f).  Freshen  up  margins  of  the  nasal  defect  and  suture  in  this  new 
flap  as  in  1  he  usual  Italian  met  hod. 


PLASTIC  SI;K<;KKY  OF  TIIK   XOSK  AND  KAK. 


Two  Weeks  L< 

(J.     Sever  pedicle  and    readjust    the   parts  to    form    the    ala-    and 
columella. 

Nelaton  's  Operation. 

1.      Form  a  pedicle  (lap  from  the  forearm  and  attach  to  the  mar- 
gins of  the  defect.    (  Fiir.  _!()!'. ) 


Kim.  269. 
Nolaton's  oporation. 

Tico  H'tv/rx  Later. 

'2.     Sever  the  pedicle. 

3.  Form  two  Ha])S  from  the  outer  margin  of  the  alar  openings 
outward  and  downward  as  low  as  the  inferior  maxilla  in  the  naso- 
labial  fold.  (Fig.  270.) 


310 


OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 


4.  Turn  these  so  as  to  make  skin-lined  nostrils  and  also  a  colu- 
inella  or  septum  support  for  the  new  formed  flay),  which  should  also 
include  a  small  flap  for  the  formation  of    a    double  columella.     (Fig1. 
271.) 

5.  Suture  these  flaps  to  one  another  and  close  the  defect  in  the 
nasolahial  fold.    (Fig1.  1271.) 

Tiro  Weeks  Later. 

6.  Sever  the  pedicles  of  the  two  flaps  and  adjust  them  to  the  ala> 
of  the  nose.     Also  reconstruct  the  columella. 


Fig.  27n.  Fig.  271. 

Nelaton's   operation. 


III.     HINDOO    OR    INDIAN    METHOD. 

This  is  by  far  the  preferable  method  when  there  is  so  much  de- 
struction of  the  nose  that  insufficient  tissue  is  obtainable  in  the  imme- 
diate neighborhood,  as  the  cheeks  or  the  nose  itself.  'The  Haps  may 
vary  as  to  their  shape  and  outline,  according  to  the  area  to  be  cov- 
ered and  according  to  the  area  of  the  ahe  or  upper  portion  of  the  nose 
that  is  present  or  can  be  ntili/ed.  (Fig.  '27 '2. ) 

The  character  and  extent  of  the  defect  determine  the  side  of  the 
forehead  from  which  the  (laps  are  to  be  made.  In  this  particular,  the 
flaps  should  be  so  constructed  that  the  pedicle  should  contain  the  angu- 
lar artery,  which  should  be  subjected  to  very  little  twisting.  In  fact 
no  tension  must  be  exerted  anywhere  on  these  (laps.  The  Haps  may 


I'LASTIC    Sl'KOKKY     OK    Tl  I K     NOSK    AND    KAI{. 


bo  formed  of  the  skin  and  part  of  its  underlying  connective  lis>u<-  only, 
or  they  may  contain  the  periosteum  and  even  a  portion  of  the  external 
table  of  the  frontal  bone.  The  frontal  defects  thus  created  by  the  turn- 
ing of  the  Hap  may  be  covered  in  several  ways.  l>y  loosening  up  the 


Fig.  272. 
Hindoo  or  Indian  method  of  flap  formation. 


Fig.  273. 
Thiersch's  operation   for  total  loss  of  nose. 


31'2  OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,,    AND    EAR. 

margins  and  drawing'  the  parts  together  as  far  as  possible,  the  granu- 
lation may  be  encouraged;  a  Thiersch  skin  graft  may  be  used,  or  the 
entire  area  may  be  covered  by  skin  graft  (Thiersch,  Wolfe  or 
Krause).  After  union  takes  place  the  pedicle  is  severed  and  the 
stitches  are  removed.  It  requires  usually  about  eight  to  ten  days  be- 
fore the  pedicle  is  cut  off,  and  it  is  frequently  very  thick  and  large,  so 
that  it  must  be  trimmed  off  and  adjusted  to  the  still  existing  defect 
between  the  eyebrows  and  root  of  the  nose. 

Thiersch  's  Operation  for  Total  Loss  of  Nose. 

1.  Make  two   small  quadrangular  flaps   from   the   cheeks   at  the 
lower  portion,  forming  their  hinge  at  the  side  of  the  nose  where  they 
will  constitute  the  inner  surface  of  the  nostrils  and  ala  of  the  nose. 
(Fig.  273.) 

2.  Dissect  them  loose  and  turn  them  with  their  dermal  layer  to- 
wards the  nasal  cavity. 

3.  Suture  one  to  the  other  in  the  median  line. 

4.  Make  a  frontal  pedicle  flap  and  suture  into  the  freshly  denuded 
margins  on  the  side  and  lower  part  of  the  nose.     (Fig.  273.) 

5.  Cover  newly-formed  defects  by  Thiersch  grafts. 

Nelaton's  Operation  for  Total  Loss  of  Nose  (Indian  Method). 

1.  Expose  entire  length  of  costal  cartilage  of  the  eighth  rib. 

2.  Excise. 

3.  Trim  down  to  a  size  2.f)  cm.  long  by  3  mm.  wide. 

4.  Cut  a  notch  where  the  point  of  the  nose  is  to  be  formed  by  this 
cartilage,  that  is,  about  0.75  cm.  from  the  end  nearest  to  the  base  of  the 
forehead  pedicle. 

5.  Outline  the   forehead   flap. 

6'.  Incise  the  base  of  this  flap  down  the  bone  for  about  0.5  cm.  and 
make  a  tunnel  to  fit  the  cartilage  strip. 

7.  Introduce  cartilage  strip  with  its  notch  towards  the  skin  in- 
cision so  that  it  is  between  the  frontal  bone  and  its  periosteum.  (Fig. 
274.  ) 

*.      Close  skin-periostea!  incision. 


li*    f.tl/rr. 

!>.  Make  an  incision  about  the  nasal  defects  in  such  a  manner  that 
two  lateral  and  one  upper  central  flap  will  result.  (Fig.  274.) 

1.0.  Turn  these  over  so  that  the  skin  surfaces  will  look  into  cav- 
ity of  nose. 

11.      Stitch  with  catgut   so  as  to  retain  them   in   position. 


Fig.  274. 


Fig.  -21->.  Fig.   -2!*. 

Xelaton's  operation   for  total   loss  of  nose. 


314  OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAE. 

1:2.  Cut  forehead  flap  with  its  pedicle  towards  the  opposite  inner 
corner  of  the  eye,  over  which  the  flap  is  situated  as  shown  in  Fig.  275. 
This  flap  contains  the  previously  introduced  cartilage  with  its  under- 
lying periosteum. 

13.  Turn  the  flap  downward,  over  the  previously    turned    flaps 
made  from  the  margin  of  the  defects.  The  flap  should  be  fashioned  into 
a  sort  of  a  tip  of  the  nose  by  bending  the  cartilage  where  the  notch  had 
been  cut  in  it,  so  as  to  make  a  proper  columella. 

14.  Stitch  in  place.   (Fig.  276.) 

15.  The  defect  in  the  forehead  is  closed  by  skin  graft  or  sliding 
flaps.    [Author's  comment. — This  forehead  defect  can  be  covered  rnnch 
better  by  sliding  the  skin  and  making  counter  release  incisions  in  the 
hairy  portion  of  the  scalp.] 

One  Week  Later. 

16.  Cut  pedicle,  trim  it  and  implant  in  existing  defect  at  the  root 
of  the  nose. 

Koenig's  Operation  (Indian  Method). 

1.  Make   a   transverse   incision   across   the   depressed   portion   of 
nose  into  the  nasal  cavity  and  dissect  loose  the  tip  of  the  nose,  so  as  to 
bring  it  into  a  more  horizontal  position.    (Fig.  277.) 

2.  Make  a  strip-shaped  flap  from  the  root  of  the  nose  straight 
towards  the  hair  line,  all  tissues  being  severed  to  the  bone.    (Fig.  277.) 

.').  AVith  a  small  chisel  cut  through  the  external  table  along  the 
course  of  the  incision  made  in  this  strip-shaped  flap. 

4.  Take  off  this  layer  of  external  table,  periosteum  and  skin  and 
turn  it  downward  into  the  newly-formed  defect,  bringing  the  upper- 
most margin  of  the  strip-shaped  flap  below  the  lower  margin  of  the 
defect,  and  stitch  it.   This  causes  the  skin  surface  to  look  into  the  nasal 
cavity  while  the  raw  bony  surface  is  external.    (Fig.  278.) 

5.  Break  the  curved  bony  bridge  of  this  turned  down  flap  so  as  to 
give  a  curve  to  the  nose. 

6.  Make  a  lateral  frontal  flap  and  turn  it  down  in  the  usual  man- 
ner by  twisting  a   pedicle  covering  the  denuded   bony  surface.     (Fig. 
277.)  * 

7.  Subsequent  trimming  of  the  pedicle  at  the  root  of  the   nose, 
with   readjustment    of  the   newly-formed    irregularities   at    this    point 
must  follow,  that  is,  excision  of  the  skin  between  the  root  of  the  nose 
and  the  narrow  (lap.    (Fig.  271'.) 


PLASTIC    SURGERY    OK    TJIK    NOSH    AND    EAR. 


Fig.  279. 


Koenig's  operation. 


3lO  OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

Keegan's  Operation  for  Subtotal  Loss  of  Nose,   in   Cases   of   Hacked 
Noses  (Indian  Method). 

1.  Two  flaps  are  formed  from  the  remaining  skin  over  the  nasal 
bones,  leaving  their  broad  pedicles  attached  at  the  bony  margins  of  the 
deformed  nose.  (Fig.  280.) 


mail's   op. 'nit  ion    for   subtotal    loss  of   nose,    in   cases   of   hacked   noses. 


PLASTIC    Sl'HOKKY    OF    THK    NOSH    AND    KAK.  -'517 

2.  These  two  (laps  arc  <lisscctc<l  off  and  turned  at  the  hinged  ped- 
icles with  their  dermal  surfaces  towards  the  nasal  cavity.  They  are 
sutured  together  and  into  the  lloor  of  the  nose.  (  Fig.  2*1.) 

.'!.  The-  denuded  surface  from  the  root  of  the  nose  to  where,  the 
tip  is  to  he  formed,  is  now  covered  with  a  frontal  flap  which  is  so  con- 
structed as  to  bring  the  pedicle  at  one  or  the  other  inner  angle  of  tin- 
eye,  that  is,  an  oblique  flap.  (Fig.  281.) 

4.  Suture  the  above  (lap  in  place  making  a  columella  out  of  the 
remaining  portion  with  the  aid  of  the  frontal  flap  extension. 

f).  Close  the  defect  in  the  forehead  as  shown  in  Fig.  2*1,  and 
cover  any  raw  portions  with  skin  graft  of  Thiersch  or  Wolfe. 

G.  After  ahout  ten  days,  sever  the  pedicle  and  implant  properly, 
reconstructing  the  skin  over  the  root  of  the  nose. 

Nelaton's  Operation  for  Subtotal  Loss  of  Nose. 

1.  An  incision  in  the  form  of  an  A   is  made,  the  apex  of  the  A 
coming  close  to  the  hair  line  (Fig.  282 )  and  continuing  laterally  to  the 
nasal  defects. 

2.  By  means  of  a  fine  saw  the  skin  and  underlying  hone  of  the 
frontal  nasal  and  superior  maxilla  are  taken  along  in  the  shape  of  a 
triangular  Hap  (Fig.  28.'!),  leaving  the  attachments  at  the  ahv. 

.'!.  Tt  is  then  bent  into  the  shape  of  the  tip  of  the  nose  point  and 
folded  so  that  the  uppermost  point  of  the  flap  comes  in  between  the 
eyebrows.  (Fig.  2S4.) 

4.     Suture  in  this  position.    (Fig.  28").) 

.1.     Close  forehead  defect  by  sliding  flaps. 

Von  Langenbeck's  Operation  for  Collapsed  Nose;  Making  Supports, 
Especially  When  Soft  Parts  are  Wanting  (Osteoplastic). 

1.  An  incision  is  made  on  the  side  of  the    nose    from    the    nasal 
process  of  the  frontal  bone  to  the  floor  of  nose.    (Fig.  28(1.) 

2.  Dissect  the  skin   laterally  so  as  to  expose  the  apertura   pyri- 
formis  and  the  bones  that  are  to  be  employed,  namely  nasal  bones  and 
the  nasal  process  of  the  superior  maxilla. 

.').  With  a  small  saw  or  chisel  cut  from  above  downward  a  small 
strip  of  bone  on  each  side  of  the  margin  of  the  apertura  in  such  a 
manner  as  to  leave  its  lower  attachment  at  the  superior  maxilla.  (Fig. 
286.) 

4.  Elevate  these  two  pieces  of  bone  outward  and  bring  over  them 
the  previously  dissected  skin  which  is  further  sutured  to  these  bone 
] (articles.  (Fig.  28(5.) 


318  OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 


Fig.  282. 


Fig.  284. 


Fig.   28:5.  Fig.  285. 

NY-hit on's  operation   for  subtotal  loss  of  nose. 


PLASTIC    Sl'HCKHV    OF    TIIK    XOSK    AND    HAH. 


f).     A   similar   procedure   is   practiced   on   the   nasal    hones,   which 
arc  usually  depressed.     They  are  sawed  or  chiseled  off  from  the  nasal 
processes  of  the  superior  maxilla   and   elevated,    leaving  their  attach 
inent  with  the  frontal  hone  as  a  sort  of  hiiitfe.    (Kit;:.  1'S?. ) 

(i.  Form  a  proper  forehead  Hap  and  cover  this  newly-made  bony 
support,  and  suture  in  the  usual  manner. 

Schimmelbusch's  Operation  for  Total  Loss  of  Nose. 

1.  Cut  out  a  rhomboidal-shaped  Hap  from  the  forehead  with  the 
broad  part  above,  measuring  2  to  .')  cm.  between  the  margins  below  and 
0  to  7  cm.  at  its  upper  part.  Its  length  should  depend  on  the  length  of 
the  nose  to  be  covered.  This  incision  includes  the  periosteum. 


Fig.  286. 


Fig.  287. 


Von     Langenbeck's    operation     for    collapsed    nose;     making    supports. 
especially   when   soft    parts   are    wanting. 

'2.  By  means  of  a  broad  chisel  a  thin  plate  of  bone  is  taken  away 
with  this  Ha]);  in  most  instances  it  will  be  in  several  pieces,  although 
endeavor  should  be  made  to  keep  the  periosteum  attached.  (  Fiu\  2S8.) 

.').  Turn  this  skin-boue  Map  down  and  in  order  to  prevent  these 
bone  plates  from  falling  off,  a  sort  of  lattice  work  of  silk  thread  should 
be  passed  about  this  flap  and  covered  with  irau/e  to  allow  .u'ranulation 
to  form. 

4.  Cut  out  two  curved  skin  Haps  as  shown  in  Fii>'.  2SS,  to  allow 
the  sliding  forward  of  the  lateral  skin  Hap  for  the  closure  of  the  frontal 
defect. 


320  OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,,    AND    EAR. 


Fig.   288. 


Fig.   28!).  Fig.  2!H 

Schimniolbusch's   operation    for   total    loss   of  nose. 


PLASTIC    SUIUJEKY    OF    THE    NOSE    AM)    KAK.  .'{21 

f).  Continue  incision  up  to  the  periosteum  in  a  curvo-linear  man- 
ner back  of  the  ear  and  loosen  the  entire  lateral  flap.  (Fig.  2K9.) 
This  is  done  on  both  sides. 

(>.  Slide  the  two  lateral  flaps  so  as  to  make  them  meet  in  the  cen- 
ter of  the  forehead  and  also  join  the  skin  where  the  two  little  flaps 
were  removed.  As  a  result  there  will  be  two  small  defects  on  the  side 
of  head,  which  can  be  allowed  to  .granulate  and  can  be  corrected  subse- 
quently. 

Four  to  Si,)'  Week*  Later. 

I.  By  means  of  a  saw  divide  the  bony  portion  of  the  nose  to  be 
formed,  and  shape  it  in  the  form  of  a  trough.     In  the  event  that  the 
pedicle  is  again  adherent  at  the  root  of  the  nose,  it  should    be    thor- 
oughly loosened  and  the  flap  turned  with  its  dermal  surface  outward. 
(Fig.  289.) 

8.  To  form  the  eolumella,  dissect  off  from  each  side  of  the  pyri- 
form  aperture  two  skin   flaps  and   unite  them  as  shown   in  Fig'.   289. 
This  will  leave  their  pedicle  attachment  at  the  usual  insertion  of  the 
eolumella  and  their  free  end  is  to  be  attached  to  the  newly-formed  tip 
of  the  nose. 

Three  Weeks  Later. 

9.  Freshen  up  the  lateral  portion  of  the  defect,  especially  at  the 
apertura  pyriformis  and  dissect  away  the  skin  so  as  to  lay  bare  the 
bony  margins  of  the  defect.     The  good  result    of    this    procedure  de- 
pends upon  this,  since  the  implantation  of  the  bony  portion  of  the  new 
nose  on  a  raw  and  bony  area  makes  a  substantial  support.     Sutures 
through  the  bone  are  additional  supports  for  g'ood  union. 

10.  Pass  a  wire  through  the  lower  portion    of   the    nose,    trans- 
versely, and  fix  by  two  small  rolls  of  gauze  or  small  rubber  tubing  so 
that  the  wire  does  not  cut  in.     The  purpose  of  this  wire  is  to  insure  a 
roof-like  form  to  the  bridge  of  the  nose.    (Fig.  290.) 

II.  Sever  the  pedicles  of  the  frontal  flaps  of  the  nose  and  place 
them  into  the  defect  where  the  two  lateral  flaps  join  in  the  middle  of 
the  forehead.    (Fig.  290.) 

Schimmelbusch's  Operation  for  Saddle-back  Nose. 

1.  Prepare  the  frontal  (skin-bone)  flap  in  the  same  way  as  in  the 
Scliimmelbusch  operation  for  total  loss  of  nose,  and  make  the  lateral 
flap  in  the  same  manner,  uniting  the  created  defect  newly-formed  in 
similar  manner. 

2.  Turn  the  frontal  flap  directly  down  without  twisting  the  ped- 
icle, that  is,  the  skin  downward  and  bone  externally,  cover  the  flap  with 


322  OPERATIVE    SURCJEKY    OF    THE    XOSE,    THROAT,    AND    EAR. 


Fig.   291. 


Scliiiniiiclbiisch's    o])cration    I'o:1    saddli'-liack    nose. 


PLASTIC    SUHCKHV    OF    TIIK    XOSK    AND    KAH.  .j_.J 

the  thread  lattice  work  to  prevent  the  dislodgment    of    the    hone    and 
wra])  the  whole  Hap  in  gauze  to  allow  the  hone  to  granulate. 

(hie  Week  Later. 

.').  Make  a  vertical  incision  in  the  middle  of  the  bridge  of  the  nose 
and  cut  loose  subcutaneously  the  lower  part  of  the  cartilaginous  por- 
tion of  the  nose,  so  as  to  bring  down  the  tip,  making  an  opening  into 
the  nasal  cavity  with  the  nostril,-;  looking  downward.  (Fig.  291.) 

4.  Freshen  up  the  bony  apertura  pyriformis  and  dissect  the  skin 
freely  from  the  side  of  tlie  nose. 

f).  Saw  and  break  the  bony  portion  of  the  frontal  flaps  in  such 
fashion  as  to  give  a  roof-like  appearance.  (Fig.  291.) 

6.  To  insure  healing,  trim  off  the  dermal  layer  of  the  frontal  flap 
where  it  will  come  in  contact  with  the  tissues  about  the  apertura  pyri- 
formis. 

7.  Place  the  frontal  flap  in  position  between  the  dissected  lateral 
skin  margins  of  the  nose  and  firmly  against  the  apertura  pyriformis, 
where  an  anchor  suture  may  be  placed  and  brought  out  at  the  outer 
corner  of  the  al.T.    (Fig.  292.) 

Our  Week  Later. 

8.  Sever  the  pedicle  at  the  root  of  the  nose  in  such  a  manner  as 
to  utilize  as  much  of  the  turned  over  skin  as  possible  to  fit  into  the 
still  remaining  defect  between  the  eyes,  where  the  two  lateral  parietal 
flaps  come  together,  and  then  suture. 

9.  Freshen  up  the  lateral  skin  margins  of  the  nose  and  bring  to- 
gether over  the  middle  of  the  nose.    (Fig.  293.) 

Sir  Watson  Cheyne's  Operation  (Indian  Method). 

1.  An  incision  is  made  in  the  median  line  of  the  nose  over  the 
cartilaginous  portion.  (Fig.  294.) 

'2.  Two  transverse  incisions  are  made  at  each  end  of  the  first  in- 
cision, forming  two  lateral  flaps  when  dissected,  like  an  open  door. 
(Fig.  294.) 

o.  Dissect  these  lateral  flaps  and  take  along  any  fragments  of 
nasal  bones  or  periosteum  that  may  be  attached  to  them.  (Fig.  295.) 

4.  Sever  the  cartilage  from  the  bony  portion  of  the  external  nose 
and  cut  into  the  septum  so  as  to  pull  down  the  point  of  the  nose  in  the 
proper  shape. 

5.  Two  vertical  incisions  are  now  made  slightly  above  the  root 
of  the  nose  and  about  one-eighth  of  an  inch  from  the  median  line,  as 
far  ii|)  as  the  line  of  the  hair.     A  third  transverse  incision  unites  these 


::-J4 


OPERATIVE    SURCERY    OF    THE    XOSE,    THROAT,    AND    EAH. 


Fig.  295. 


Sir   Watson   Clicync's   operation.      (Indian    method. 


PLASTIC    SfUCKKY    OF    TIIF.     NOSK    AND    K.AIi. 

t\\'o  vertical  ones  at  the  hair  line.     These  three  incisions 
structures  down  to  the  bone.     (Fig.  294.) 

(i.  Insert  a  narrow  chisel  along  the  margin  of  these  three  incis- 
ions and  separate  a  portion  of  the  external  table  of  the  frontal  hone, 
leaving  it  attached  to  the  periosteum  and  the  remains  of  the  flap.  (  Fiir. 
29f>.) 

7.  This  whole  flap  is  now  turned  downward  so  that  the  skin  is 
looking  into  the  nasal  cavity  while  the  outer  surface  comprises  the  de- 
nuded bones. 

S.  Shave  off  the  epidermis  at  the  root  of  the  nose  as  well  as  at 
the  uppermost  portion  of  this  turned  down  flap  so  that  these  two  may 
adhere  at  this  point. 

9.  Suture  the  lowest  point  of  this  turned  down  flap  to  the  fresh- 
ened cartilaginous  portion  of  the  nose  that  was  pulled  down,  thus  clos- 
ing the   nasal   defect.      Care   should    be   exercised   at    this   point    not   to 
bend  the  upper  pedicle  too  acutely  and  not  to  have  any  tension  what- 
soever.     If  there   he  trouble  of  this   sort,  two   little   incisions    may    be 
made  on  the  side  of  the  nose  from  the  base  of  this  flap  and  the  tension 
thereby  relaxed.    (Fig.  296.) 

10.  Unite  the  defect  on  the  forehead. 

11.  The  lateral  flaps  are  now  replaced  and   united  over  the  raw 
bony  surface  of  the  forehead  flap,  also  above  and  below.     (Fig.  297.) 

Tiro  or  Three  JJVrVrx  Later. 

12.  The  pedicle  is  cut,  turned  back  to  till   up  the  defect  and  any 
irregularity  trimmed  down  and  corrected;    any    granulating  surface 
may  be  covered  by  skin  graft. 

Von  Hacker's  Operation  (Indian  Method). 

1.  Outline  the  usual  flap  from  forehead  with  pedicle  at  the  root  of 
the  nose. 

2.  Dissect  the  skin  on  the  three  free  margins  of  the    flap    to    a 
point  in  the  median  line  measuring  S  mm.  in  width  and  the  full  length 
of  the  flap;  this  portion  is  to  form  the  subsequent  bony  support  of  the 
newly-formed  nose. 

.'>.  The  dissected  skin  is  now  sutured  temporarily  in  the  median 
line  by  two  or  three  interrupted  sutures  and  a  few  small  pins  driven 
into  the  bone-periosteal  flap  (Fig.  29S)  in  order  to  facilitate  its  dissec- 
tion. 

4.  By  means  of  a  chisel  this  bone-periostea!  skin  flap  is  now  sev- 
ered ii])  to  the  root  of  the  nose,  where  the  pedicle  only  consists  of  skiii 
and  periosteum,  in  order  to  be  able  to  twist  it  easily.  (Fig.  299.) 


326  OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 


Fig.  l^'.t. 


Fig.  :w>. 


Von    Hacker's  operation.        (Indian    method.) 


' LA  STIC    STKiiKKY    OF    TIIK    XOSK    AND    KAK. 


5.  Break  away  the  entire  (lap  and  rotate  downward  into  the 
proper  position,  having  previously  prepared  the  defect  for  union  by 
freshening  up  the  margins  and  the  remains  of  the  septum  with  which 
the  bony  bridge  is  to  come  in  contact.  This  bony  strip  is  broken  at 
the  lower  portion  and  a  proper  point  of  the  nose  is  formed.  It  is 
sutured  into  the  floor  of  the  nose  and  a  columella  and  ahe  are  formed 
from  the  skin  flap.  Rubber  tubes  are  inserted  into  nostrils  to  give 
shape  to  them.  (Fig.  ."00.) 


f 

Fig.  301.  Fig.  302. 

Sedillot's  operation  for  total  loss  of  nose.     (Indian  method.) 

Sedillot's  Operation  for  Total  Loss  of  Nose  (Indian  Method). 

1.  Form  a  tongue-shaped  flap  from  the  upper  lip,  not  going 
through  the  mucous  membrane,  placing  the  pedicle  at  the  nasal  floor. 
(Fig.  .",01.) 

'2.  Form  a  forehead  Hap,  taking  care  to  make  a  longer  median 
flap  for  the  formation  of  the  columella. 

I!.     Freshen  up  the  nasal  defect. 

4.  Bring  down  frontal  flap  and  suture  in  laterally,  and  to  form 
the  columella  suture  central  flap  to  the  little  flap  from  the  lip  in  such 
a  manner  that  there  is  skin  surface  externally  as  well  as. in  the  nose:  in 
other  words,  one  on  to])  of  the  other.  (Fig.  .'>0l?.) 

IV.     Double  Transplantation  Method. 

A  skin  flap  may  first  be  made  from  the  chest  or  abdomen  and  at- 
tached to  a  part  of  the  hand  or  forearm,  and  after  it  lias  healed  on  and 


.11:0  OPERATIVE    SUROERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

ii'ood  circulation  has  been  established,  it  is  severed,  and  then  attached 
to  the  nose  as  in  the  Italian  method.  Or  a  toe  from  which  the  nail  has 
been  removed  is  implanted  into  the  palm  of  the  hand,  and  after  it  is 
thoroughly  healed  it  is  severed  and  made  ready  to  use  in  constructing 
a  firm  support  for  a  nose.  Bone  which  has  been  removed  from  an  am- 
putated le,i>'  and  formed  in  the  shape  of  a  nose,  implanted  under  the 
forearm  below  the  periosteum  of  the  ulna,  is  prepared  in  the  form  of 
a  pedicle  after  it  has  united  and  remained  viable  and  is  then  sutured 
into  a  nasal  defect,  as  in  the  Italian  method.  A  similar  method  is  em- 


Steintlial's    operation    for    total    loss    of    nose.      (Double    transplantation    method.) 

ployed  in  implanting  pieces  of  cartilage  under  the  skin  and  periosteum 
of  the  forehead  before  making  the  frontal  Hap. 

Steinthal's  Operation  for  Total  Loss  of  Nose. 

1.  Make  a  tongue-shaped  Hap  from  the  sternal  region  with  its 
pedicle  towards  the  sternal  notch,  measuring  •">  cm.  at  its  free  end  and 
•'!  cm.  at  the  pedicle  end,  the  length  hein^1  about  1'J  cm.  'The  Hap  is  com- 
posed of  skin  and  periosteum.  Suture  the  defect  over  sternum  in  part. 


PLASTIC    Sl'UCKKV    OK    TIIK     XOSK    AND    KAII. 


-.  Make  an  incision  through  the  skin  of  the  forearm  near  the 
\vris1  and  over  the  radius  to  accommodate  the  free  end  of  the  above 
Hap. 

.'!.  Suture  in  this  free  end  of  the  Hap  for  subsequent  transplanta- 
tion. (Fig.  :!o::.) 

4.     Apply   immobilizing  plaster  of   Paris  jacket. 


'J'/rc/rc  Dd/js  Later. 

.").     Sever  pedicle  from  sternum  and   leave  it    unattached  to  allow 
perfect  circulation  to  be  established  in  the  Hap  for  two  or  three  days. 


Fig.   305.  Fig.  306. 

Kauaeh's  operation  for  collapsed   nose.     (Double  transplantation   method.) 

b'.      Freshen  up  the  surface  at  the  nasal  defect. 

7.  Suture  free  end   of  Hap  situated  on  the   forearm   to  this  pre- 
pared surface  about  the  nasal  defect.    (Fig.  .''04. ) 

8.  Apply  again  a  retention  plaster  of  Paris  jacket  for  about  one 
week  to  ten  days. 

9.  Sever  the  Hap  from  the   forearm  and   suture  in  about  the  re- 
maining   nasal    defect    to    form    a    properly    shaped    nose,    including 
columella  and  alar  skin  lining. 

Kausch's  Operation  for  Collapsed  Nose. 

1.  Kemove  the  nail  of  the  fourth  toe  of  the  same  side  as  the  hand 
that  is  to  be  employed.  A  portion  of  the  skin  from  the  tip  of  the  toe  is 
turned  back  to  obtain  a  u'ood  raw  surface. 


330  OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

±  Make  an  incision  in  the  thonar  eminence  of  the  palm  of  the 
hand  of  a  proper  size  to  accommodate  the  tip  of  the  toe. 

3.  Bring1  hand  and  toe  together  approximating  the  tip  of  toe  to 
the  incision  and  suture  \vell  on  all  sides  of  the  skin. 

4.  Place  a  retaining  device  either  of  plaster  of  Paris  or  leather, 
to  keep  the  parts  immobile. 

T ten  Weeks  Later. 

5.  Sever  the  toe  at  the  metatarsophalangeal  joint,  leaving  it  at- 
tached to  the  hand.    (Fig.  305.)    Close  defect  in  the  foot. 

Tico  Day*  Later. 

6.  Freshen  up  the  bony  surface  at  the  floor  of  the  nose  and  the 
skin  on  the  side  of  the  nasal  defect. 

7.  Bring  hand  in  proximity  to  nose  and  suture  the  free  end  of 
the  transplanted  toe,  which  has  also  been  freshened  on,  into  the  bone 
exposed  at  the  prepared  nasal  defect.    (Fig.  306.) 

8.  Iietain  by  plaster  of  Paris  bandage  as  in  the  Italian  method. 

Tu'<>  Wf'clix  Later. 

9.  Sever  the  attachment  of  the  toe  to  the  palm  of  the  hand  and 
close  this  temporary  defect. 

10.  Remove  the  skin  from  transplanted  toe  from  the  part  that 
is  to  come  in  contact  with  the  subcutaneous  tissue  of  the  ridge  of  the 
nose.    If  the  mass  of  bone  is  too  large  one  may  bite  out  a  portion  and 
also  shape  it  in  the  form  of  a  columella  and  ridge,  giving  the  nose  a 
proper  shaped   point.     Suture  the  distal  end  towards  the  root  of  the 
nose. 

11..  Subsequent  smaller  corrections  of  making  proper  shaped 
nostrils,  etc.,  should  be  done  not  before  two  weeks,  when  the  circula- 
tion is  well  established. 

V.     Finger  Method. 

In  cases  where  a  greater  part  of  Ihe  bony  portion  of  the  external 
nose  is  absent  and  most  of  the  soft  pacts,  the  employment  of  the  finger, 
sacrificing  this  member  for  Ihe  formation  of  a  nose,  has  been  followed 
by  good  results.  The  cases  especially  suitable  for  this  operation  are 
those  in  which  the  greater  part  of  the  ala*  and  probably  the  skin  por- 
tion of  the  tip  of  the  nose  are  still  present,  even  though  this  latter  por- 
tion be  markedly  drawn  in  and  adherent. 

Watt's  Operation  for  Subtotal  Loss  of  Nose. 

1.     Sever  the  columella  at   its  attachment   to  the  upper  lip. 


PLASTIC    SrUKKKY    OK    T 1 1  K     XOSK    AND     KAII.  -'!i!l 

-.  Take  the  left  little  linger  and  remove  its  nail  an<l  matrix,  also 
the  skin  from  its  tip  anteriorly. 

.'!.  Pass  this  (in^cr  through  remnant  of  tip  of  nose  and  (i.\  at  tlie 
root  of  the  nose  close  to  the  frontal  hone  by  means  of  silver  wire,  an 
area  having  been  prepared  in  this  region.  (Fi,u\  .'107.) 

4.  Apply  a  plaster  east  to  hold  parts  immobilized  in  place. 

Tu'o    UVr/.'.s'   Ldfrr. 

5.  Amputate   tinker  at  metacarpophalangeal  joint  and   close  de- 
fect in  hand. 

A  Fete  7)r///.s'  Later. 

6.  Trim  down  the  free  end  of  the  finder  so  as  to  make  it  narrow 
enough  to  obtain  two  separate  nostrils. 


Fig.  307 
Watt's  operation  for  subtotal  loss  of  nose. 


an- 


7.    Push  this  end  of  the  linger  into  the  nasal  cavity  and  fix  by 
other  suture. 

S.     Suture  back  the  previously  severed  columella  to  the  lip  by  re- 
freshing their  surface. 

One  Week  Later. 

9.  "Remove  skin   from  dorsum  of  the   now  healed-in   finder  at  the 
nasal  defect. 

10.  A  flap  from  the  forearm  is  made  and  sutured  in  above  the  de- 
fect,   fixed    airain    by    plaster    jacket    and    treated    as    in    any    Italian 
method. 


OI'KHATIVE    SURCKRY    OF    THE    XOSK,    THROAT,    AXD    EAR. 


Fig.   308. 


Fig.   309. 


Fig.   :ilO.  Fig.   :ni. 

\\"<ilko\vitsch's   ope  ration    for   total    loss   of   nose.      (Finger    method.) 


I'LASTIC    SrUliKHY    OF    T  1  1  K     N()SK    AND    KAII.  .'J.'J.'I 

Wolkowitsch's  Operation  for  Total  Loss  of  Nose  (Finger  Method). 

I.  Take  the  fourth  linger  of  the  left  hand. 

-.  Make  a  median  incision  ovei-  the  dorsal  surface  of  the  same 
from  the  metacarpophalangeal  joint  to  the  nail,  through  the  skin  and 
siihcutaiieous  tissue. 

.'!.      Dissect  loose  to  cither  side  f  reels'. 

4.  Remove  the  nail  and   he  sure  of  the  removal  of  all  of  its  mat- 
rix.   Tendon  must  not   he  disturbed.    (Fig.  .'JO*.) 

.").  Remove  the  skin  from  the  tip  of  the  finder  in  front  for  its  at- 
tachment at  the  root  of  the  nose. 

(i.  Split  the  skin  and  underlying  tissues  through  to  the  hone  in 
the  median  line  at  the  root  of  the  nose,  and  separate  freely  to  eith-T 
side,  including  the  margins  of  the  remaining'  apertura  pyriformis. 

7.  In  the  bony  structures  at  the  root  of  the  nose  make  a  dent  by 
means  of  a  gouge,  into  which  the  tip  of  the  finder  \vill  fit  so  as  not  to 
make  a  perceptible  hum])  at  this  point.  (Fig1.  .'50!).) 

5.  Bring1  the  finger  to  the  prepared  area  of  the  nose  and  tuck  its 
skin  Haps  below  the  dissected  lateral  Hap  about  the  apertura  pyrifor- 
mis, the  tip  of  the  finger  being  fitted  into  the  depression  at  the  root. 

!'.  Fasten  the  finger  at  the  root  by  sutures,  as  in  Fig.  .'510,  and 
stitch  the  skin  flaps  of  the  finger,  which  are  tucked  under  the  dissected 
skin  of  the  nose  defect,  with  two  mattress  sutures  on  each  side. 

10.  (Mose  the  median  incision  at  the  root  of  the  nose  as  far  down 
over  the  finger  as  possible. 

II.  Place  a  quantity  of  marly  (Scotch  gau/e)  below  the  finger  to 
hold  it  u]»  in  the  shape  of  a  nose  and  place  a  dressing  over  the  surface. 
Then  apply  a  fixation  bandage  as  in  any  Italian  operation. 


]'2.  Remove  the  stitches  and  extend  the  incision  over  the  dorsum 
of  the  hand  so  as  to  expose  the  entire  metacarpophalangeal  joint  tor 
excision. 

!.">.  Dissect  the  skin  laterally  and  incise  it  on  either  side  of  the 
finger,  but  do  not  sever  in  front  at  this  time. 

14.  During  the  next  five  days  in  two  separate  sittings  the  skin 
pedicle  is  severed  and  the  metacarpophalangeal  joint  disarticulated. 

1.").  Cover  the  defect  on  the  hand  as  in  a  regular  disarticnlation 
operation  by  the  remaining  skin  anteriorly. 

K).  Bend  and  shape  the  now  attached  finger  in  the  form  of  a  nose, 
place  some  more  marly  below  it  and  allow  it  to  remain  for  three  more 
days  for  firmer  attachment.  (Fig.  .'Ml.) 

17.      Bend  sharply  between  the  first  and  second  phalangeal  joints 


OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 


Fig.   312. 

Von    Esmarch's    operation    for    collapsed    nose    or    absence    of    the    pre- 
maxilla  or  an  anterior  perforation  of  hard  palate. 


Fiji.  :n:{.  Kin.  :>14. 

Clavicle   method.      ((Justav   Mandry.l 


PLASTIC    SUKCEKY    OF    THK    NOSE    AND    EAR.  335 

to  such  a  decree  that  the  first  phalanx  may  be  pushed  into  the  nasal 
cavity.  *>; 

18.  Prepare  the  floor  of  the  nose  and  if  there  is  a  portion  of  sep- 
tum remaining,  remove  all  the  mucous  membrane  and  expose  its  bony 
surface. 

19.  Remove  all  the  skin  and  granulations  from  that  end  of  the 
finger  that  has  been  disarticulated  and  push  it  into  the  nose  against 
the  raw  surfaces  prepared  at  the  floor. 

20.  Dissect  now  the  lateral  margins  of  the  apertura  pyriformis 
low  down  to  where  the  a  UK  are   to  be  formed,   and   tuck  under  the 
remaining  portions   of  the   skin   flap   of  the    finger,    which    are   again 
attached  by  one  mattress  suture  on  each  side. 

21.  Cover  the  entire  denuded  surface  of  this  bony  reconstructed 
framework  with  a  Krause  flap  or  with  any  flap  either  from  the  fore- 
head  or  arm.     Further   slight   corrections,   as   formation   of   nostrils 
and  cover  for  columella,  are  subsequently  performed. 

Von  Esmarch's  Operation  for  Collapsed  Nose  and  When  There  Is  Also 
Absence  of  the  Premaxilla  or  an  Anterior  Perforation  of  Hard 
Palate. 

1.  Remove  the  nail  of  the  little  finger  of  the  left  hand  and  freshen 
up  the  tip  anteriorly. 

2.  Freshen  np  the  surface  on  the  inner  side  of  the  tip  of  the 
nose  and  what  is  still  existing  of  the  floor  of  the  nose  anteriorly.     If 
nose  is  retracted,  it  should  be  freely  dissected  and  made  movable. 

3.  Fasten  the  finger  with  wire  to  the  bone  of  the  superior  maxilla 
about  the  defect  and  stitch  to  the  soft  part  at  the  nasal  tip.    (Fig.  312.) 

4.  Apply  a  plaster  jacket. 

Two  Weeks  Later. 

5.  Disarticulate,  usually  at  the  junction  of  the  second  and  first 
phalangeal  joint. 

Two  or  Three  Days  Later. 

(>.  Freshen  up  the  margins  of  the  perforation  or  defect  at  the 
roof  of  the  mouth  and  suture  in  the  properly  prepared  stump  of  the 
finger. 

VI.     Clavicle  Method  (Gustav  Mandry). 

1.  Form  a  flap  over  the  region  of  the  clavicle,  consisting  of  skin 
and  subcutaneous  connective  tissue  and  of  the  periosteum  and  bone 
of  the  clavicle.  The  broad  pedicle  is  situated  over  the  shoulder  and 
the  free  end  at  the  sternoclavicular  articulation.  (Fig.  313.) 


3oG  OPERATIVE    SURCERY    OF    THE    XOSE,    THROAT,    AND    EAR. 

'2.  Dissect  this  skill  Hap  up  to  the  upper  and  lower  margins  of 
the  clavicle,  leaving  it  here  attached  to  the  bone. 

3.  Chisel  or  saw  out  a  sliver  of  the  clavicle  measuring  4.5  cm. 
long  by  O..j  cm.  wide  (indicated  by  <i-d]-b-l^  —  Fig.  .'>!.'>)  near  the  sterno- 
clavicular  articulation  without  detaching  the  skin  and  periosteum. 

4.  In  the  free  end  of  this  sliver  two  small  holes  are  bored   for 
subsequent  anchorage  to  the  nose. 

~).  In  the  middle  of  this  large  Hap,  right  over  the  clavicle,  a  Hap 
of  skin  and  subcutaneous  tissue  is  made  in  the  form  of  a  window, 
directing  the  pedicle  towards  the  sternoclavicular  articulation,  in 
order  to  turn  it  on  the  under  surface  of  the  bone  sliver,  in  that  way 
assuring  its  nourishment  from  both  sides,  besides  subsequently  form- 
ing a  dermal  lining  for  the  interior  of  the  nose.  This  central  Ha])  is 
turned  ISO  degrees  and  made  to  come  beyond  the  terminal  end  of  the 
bone  sliver,  where  it  is  fastened  with  the  skin  above,  thus  surround- 
ing this  bone. 

(5.  Close  this  newly-formed  central  buttonhole  in  the  large  flap 
by  a  few  interrupted  sutures.  (Fig.  .'514.  ) 

7.  Allow  this  whole  Ha])  to  rest  over  its  dissected  area  where  it 
will  attach  itself  temporarily,  getting  additional  nourishment  for  its 
sustenance. 


Font' 

S.  Separate  this  whole  pedicle,  including  the  double  skin  covered 
bone  sliver,  and  liberate  it  more  freely  by  commencing  the  outside 
incision  over  the  shoulder  and  back,  thus  giving  a  greater  motion  to 
the  Hap  for  its  adaptation  to  the  nose  region. 

!).  Freshen  up  the  nasal  area,  making  a  pocket  at  the  root  of 
the  nose  in  which  the  clavicular  bone  sliver  will  be  slipped. 

10.  Fxpose  this  bone  sliver  and  place  two  strong  sutures  through 
the   holes   which   have  been   previously  drilled. 

11.  Turn  the  head  towards  the  shoulder  where  the  Hap  is  formed, 
and    bend    it    slightly   downward    so    that    the    flap   can    be    brought    in 
close  approximation   with  the  nose  without   any  tension. 

ll'.  Bring  the  two  strong  sutures  through  periosteum  and  skin  at 
the  root  of  the  nose  and  tie  over  a  pad  of  gau/e,  fixing  the  bone  sliver 
in  the  newly-formed  pocket. 

1.'!.  Apply  a  few  additional  sutures  at  the  top  and  side  of  the  nose. 
(Fig.  ::14.) 

14.  Fix  the  head  in  the  twisted  flexed  position  in  a  plaster  cast, 
as  in  the  Italian  operation,  and  provide  proper  windows  in  the  cast 
for  feeding  and  for  dressing  of  the  wound. 


PLASTIC    St'KOKKV    OF    T I  IK     NOSK    AND    KAI!.  .JO  I 

One  Wed:  Later. 

If).  Sever  the  bridge  pedicle  at  the  place  where  il  is  decided 
thai  proper  skin  flaps  may  he  made  to  complete  the  ahe,  cohmiella,  etc. 

Hi.  Dissect  off  the  epidermis  laterally  from  the  flap  and  freshen 
iij)  the  margins  of  the  apertura  pyriformis  so  as  to  obtain  proper 


17.  Fxpose  tlie  end  of  the  transplanted  bone  sliver  and  eventu- 
ally fracture  it  so  as  to  make  a  tip  of  the  nose. 

IS.  Freshen  up  an  area  of  the  bone  at  the  floor  of  the  nose 
just  in  front  and  suture  in  this  free  end  of  the  bone  sliver. 

11).     ("over  this  by  the  newly-formed  columella. 

-0.  Turn  in  the  redundant  skin  flap  at  the  alar  region  to  line  the 
newly-formed  nostrils  and  put  in  two  small  rubber  tubes. 

L'l.  Readjust  the  shoulder  flap  and  cover  the  newly-formed  bone 
defect  with  it  as  nearly  as  possible;  what  remains  may  be  covered 
with  skin  ^raft  or  allowed  to  granulate. 

'2'2.     Subsequent  correction  on  the  nose  may  be  necessary. 

VII.     Implantation  Method. 

Aside  from  the  very  popular  and  successful  method  of  injecting 
paraffin,  many  varieties  of  implantation  operations  were  formerly  per- 
formed for  the  correction  of  defects  or  malformations.  Gold,  German 
silver,  filigree  wire,  hard  rubber,  etc.,  have  been  generally  abandoned 
for  newer  and  better  methods,  inasmuch  as  these  foreign  bodies  very 
frequently,  after  healing  in  beautifully,  became  the  seat  of  irritation 
which  necessitated  their  removal.  The  implantation  of  a  sliver  of  the 
anterior  border  of  the  tibia  was  successful  in  one  case  of  the  author's; 
in  another  it  became  necrotic  and  removal  was  required.  Senn  em- 
ployed decalcified  bone  chips  in  some  cases  of  saddleback  nose. 
Recently  the  author  removed  a  septum  by  submucous  resection,  allow- 
ing one  layer  of  perichondrium  to  be  attached  and  placed  it  in  a  dis- 
sected pocket  of  a  saddleback  nose  of  another  patient.  This  healed 
in  very  beautifully  and  resulted  in  success. 

In  another  case  three  different  implantations  were  made  into 
collapsed  ala*  which  healed  in,  but  appeared  to  have  become  absorbed. 

Another  method  advocated  recently  is  to  implant  a  mass  of  fat 
from  a  patient  upon  whom  a  laparotomy  is  performed,  into  a  dis- 
sected pocket  of  a  saddleback  nose.  The  author  has  tried  this  method 
in  one  case  and  it  appears  that  the  fat  tissue  remains  alive.  The  one 
difficulty  is  that  the  nose  looks  very  lari>'e  for  a  time  as  a  i>'reat  amount 
of  fat  is  used  to  fill  up  the  defect,  in  order  to  anticipate  the  absorp- 
tion or  shrinkage  of  the  mass. 


338 


OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 


The  employment  of  a  sliver  of  bone  from  the  anterior  border  of 
the  tibia  or  a  part  of  a  rib  is  a  method  that  has  many  advocates. 

Israel's  Operation  for  Saddle-back  Nose. 

1.  Make  an  external  incision  '2  cm.  lonij1  over  the  saddle  and 
dissect  to  all  sides  subcutaneously,  until  by  pulling  on  the  tip  of  nose 
the  appearance  is  normal.  Close  this  external  incision. 

-.  A  piece  of  bone  3  cm.  lon,<>;  from  anterior  border  of  tibia  is 
chiseled  off  and  formed  into  sharp  points  on  either  end. 

3.  From  the  interior  of  the  nose  the  previously  dissected  tunnel 
is  found  by  means  of  a  dissection  and  the  sliver  of  bone  is  introduced 
in  this  direction,  the  upper  end  of  the  bone  fragment  coming  in  contact 


Israel's  operation   for  saddle-back  nose. 

with   the   nasal   bones,  the  lower  at   the  tip   between   the   external    skin 
and  the  lining  of  the  vestibule.    (  Fiii'.  31-").) 

Goodale's  Operation  for  Depressed  Nose.    (Fi.n.  31(i.) 

Modified  by  Watson-Williams. 

1.     The  mucopcrichondriuni   is  dissected  over  the  entire  cartilag- 
inous area  on  both  sides  and  pushed  up  and  back. 

-.      Loosen  up  the  tissue  below  the  depression  int  ranasally. 

3.  ('lit    out    a    flap   of  cartilage   with    its    loosely   adherent    pedicle 
towards  the  depression.    (Fi.u1.  317.) 

4.  Slide  this  cartilage  flap  below  the  depression  and   brinu1  down 
the  mucoperie  bond  Hum  into  its  original  position.    (  Fii>'.  31 S.) 


I'LAhTIC    SUKCKHY    OK    TJIK    NOSK    AND    EAR. 


Fig.  316. 


Fig.  317. 


Fig.  318.  Fig. 

Goodale's  operation  for  depressed  nose. 


340 


OPERATIVE    SUKfiERY    OF    THE    XOSE,    THROAT.    AXD    EAR. 


5.      Hold     by    transfixing-     gold-plated      pins      for    three1     weeks. 
The  writer  suggests  silk  worm  gnt  suture  tied  over  rubber  tubing 
or  gauze.    (Fig.  319.) 

Custom's  Operation  for  Depressed  Nose  Below  the  Bridge. 

1.     Separate  the  cartilaginous  portion  of  the  depressed  nose  sub- 
cutaneously  from  the  nasal  bones  and  nasal  process  of  superior  maxilla 


Fig.  320. 


Oustoifs    operation    for    depressed    nose    below    the    bridge. 

on  either  side;  also  sever  the  cartilaginous  septum,  the  incision   being 
made  latterly   lengthwise. 

'_'.      Transfix    all    these   cartilaginous    structures    with    one   of   (  Mis-- 
lon's  needles   (  Fig.  •'>'_!()),  just   below  the  nasal   bones. 

3.  Pass  another   needle   through   the    nasal    bones   which   serve   to 
support   and   lift    the  loosened  cartilaginous   portion   of  the   nose. 

4.  Wind    a    thread    or   gaii/e    in    the    form    of   a    figure   eight    (S) 
from   the  upper  to  the   lower   needle   while  the   loosened   cartilaginous 
portion  of  the  nose  is  held  up.     (Fig.  '.'>-}.) 


PLASTIC    SCKOKKY    OK    TIIK     NOSK    AND    KAII. 


Carter's    Operation  for  Saddle-back  Nose. 

1.  J>v  means  of  a  lar^c  curved  needle,  which  is  threaded  with 
Xo.  14  silk,  one  of  the  hard  rubber  splints  is  anchored.  (  Ki.u'.  •'!__. ) 

-.  Pass  the  needle  from  within  outward  at  the  junction  of  the 
cartilage  and  nasal  bone,  just  at  the  middle  of  1  he  dorsuin.  (  Fi.u'.  '.\'2'.\.) 

.'!.      Repeat  the  first  stop  on  the  other  side  of  the  nose.    (  KILI'.  .'!J.'!.) 

4.  Apply  the  metal  (Carter's)  bridge  and  set  it  by  means  of 
the  thumb  screw  so  that  it  tits  firinlv  at  1  he  base  of  the  nose  (  l-'i^.  ill'4.) 


t\     section 


OPERATIVE    Sl'RCEHV    OF    THE    NOSE,    THROAT,    AND    EAR. 

f).  Draw  firmly  upward  on  the  two  threads  so  as  to  raise  the 
Hat  or  depressed  nose  and  tie  them  over  the  hinge  of  the  bridge. 
(Fig.  .m) 

If  the  tissues  are  fixed  or  if  it  is  impossible  to  lift  the  nose  by 
the  threads,  it  may  be  necessary  to  loosen  the  nasal  bones  from  the 
nasal  process  of  the  superior  maxilla  by  means  of  chisels  and  forceps 
and  then  by  fracturing.  The  septum  of  the  nose  may  at  times  be  so 
short  as  to  necessitate  incision.  This  treatment  is  best  carried  out 
with  the  patient  in  the  recumbent  position,  but  by  employing  adhesive 


Fig.   326. 

Carter's  operation   for  saddle-back  no.se. 

plaster  the  bridge  may  be  fastened  to  the  forehead  and  then  the  patient 
may  he  allowed  to  walk'  or  sit  up.  This  bridge  is  allowed  to  remain  in 
position  from  ten  days  to  two  weeks.  (Realising  the  interior  of  the  nose 
wit  h  I  )obell  spray  is  advised. 

Carter's  Operation  for  Saddle-back  Nose  (No.  2). 

1.      Make  a  curvilinear  incision   to  the  periosteum   from   one  eye 
brow  to  the  other,  with  convexity  of  the  incision  downward.     (  Fig.  '>-•").) 

±      Lift    the  skin     Hap  and   make  transverse  incision   through   the 
periosteum   into  the  bone. 

.'!.      Klevate  the  periosteum  upwards  for  three-eighths  of  an  inch. 


I'LASTIC    SritCKKY    ()!••    T  1 1  K     NOSK    AND    KAII.  )»4.'» 

4.  Klevate  the  skill  and  subcutaneous  tissue  over  the  dorsum  of 
the  nose  and  side  of  the  cheeks  as  far  as  the  deformity  exists. 

5.  Remove  a   strip  of  the  ninth   rib,   with    periosteum,  about    two 
inches  long  and   split   it   transversely  so  as  to  shape   it    to  correct    the 
deformity. 

(i.     Scrape  the  cancelloiis  tissue  off  the  bone. 

7.  Without  removing  the  blood  from  the  prepared  pocket,  insert 
the  bone  graft  as  far  down  the  tip  of  the  nose  as  necessary  and  place  the 
upper  end  well  under  the  periostea!  Hap.  (Fig.  .'!_!(>.) 

S.     (Muse  the  skin  Hap  with  horse  hair  sutures. 

!*.      Apply  collodion  dressing. 

Beck's  Method  for  Saddle-back  Nose. 

1.  Lift  up  tip  of  the  nose  and  make  a  small  semicircular  incision 
in  the  anterolateral  portion  of  the  vestibule  at  the  mucocutaneous  junc- 
tion of  the  cartilage  and  bone. 

'2.  With  Mayo's  scissors  dissect  over  the  hump  as  in  Fig.  .'Il'b' 
With  the  same  scissors  engage  and  sever  the  hump  which  is  usually 
made  ii])  of  cartilage. 

.'>.  Kmploy  a  portion  of  the  rib,  the  anterior  surface  of  the  tibia, 
or  a  portion  of  the  septal  ridge,  from  the  patient  himself  or  from  an- 
other patient  who  has  just  been  operated  on  for  siibmiicous  resection. 
The  size  of  the  bone  splinter  should  correspond  to  the  si/e  and  shape  of 
the  deformity  to  be  corrected. 

4.  The  blood  expressed  from  the  cavity  is  mopped  away  and 
an  adhesive  plaster  is  drawn  tightly  over  the  bridge  of  the  nose  with  no 
dressing  between  it  and  the  skin. 

f).      One  silk  stitch  closes  the  wound. 

Walshaus'  Operation  for  Collapsed  Alae. 

1.  Make  a  Hap  of  the  mucous  membrane  of  the  most  anterior 
portion  of  septum,  one-eighth  of  an  inch  wide  and  one-half  of  an  inch 
long,  leaving  the  pedicle  at  the  dorsum  of  the  nose.  (Fig.  '.\'2~.) 

'2.  Roll  up  this  mucous  membrane  Hap  and  fasten  in  the  upper 
angle  of  the  nostril.  (Fig.  .'>l27.) 

'.}.     Repeat  the  same  on  the  opposite  nostril. 

Lambert  Lack's  Operation  for  Collapsed  Alae. 

1.  Remove  a   strip  of  mucous  membrane   from  the  right   side  of 
the  most  anterior  portion  of  the  septum,  measuring  about  one-eighth 
inch  wide  and  one-half  inch  long. 

2.  Cut  through  the  cartilage  and  mucous  membrane  into  the  left 
nostril  corresponding  to  the  defect,  leaving  however  the  Hap  intact  at  its 
hinge  pedicle  at  the  dorsum  of  nose. 


OPERATIVE    SUROERY.     OF    THE    NOSE,    THROAT,    AND    EAR. 

:].  Denude  the  surface  of  its  mucous  membrane  where  the  septum 
and  lateral  cartilage  of  ala  come  together;  also  of  the  dermal  layer  of 
the  inner  side  of  the  ala. 

4.  Turn  the  cartilage  mucous  membrane  Hap  up  in  the  right  nos- 
tril placing  the  two  denuded  surfaces  together. 

").  Make  a  similar  flap  back  of  this  one,  only  reversing  the  denu- 
dation on  the  septum. 

(>.  Turn  this  flap  into  the  left  side  and  fix  to  a  similarly  denuded 
surface  of  the  ala,  only  further  back.  (Fig.  .°>28.) 


a 


Fig.  327.  Fig.  :-!i>8. 

Walsliaus'  operation   for  collapsed  alae. 

Paraffin  Injections  in  Nose  and  Ear  Deformities. 

The  history  of  this  means  of  correcting  nose  and  ear  deformities 
dates  back  to  1900,  when  (lersuny  corrected  a  saddle-back  nose  by  the 
use  of  melted  vaselin,  injecting  it  below  the  skin.  Eckstein  in  11)01  em- 
ployed hard  paraffin  which  has  a  melting  point  of  140  V.  for  similar  de- 
fects, and  claimed  for  it  superiority  in  that  there  was  less  chance  for 
pulmonary  embolism.  This  method  was  very  warmly  received  and 
employed  by  Broeckaert,  Brindel,  Karenski,  Lake,  and  others  abroad 
and  by  Harmon  Smith,  Kolle,  (^uinlin  and  others  in  the  I  nited  States. 

The  principal  indication  for  paraffin  injection  is  deficiency  of  tis- 
sue about  the  nose  or  ears,  since  excessive;  growth  or  absence  of  tissues 
of  the  external  nose  and  ears  are  not  within  the  limits  of  this  method  of 
treatment.  Frequently  there  are  post-traumatic  or  inflammatory  con- 
ditions about  the  nose  which  leave  scars  and  adhesions  that  will  pre- 
vent proper  injection  of  paraffin.  In  such  cases,  preliminary  dissec- 
tion or  loosening  of  these  scars  may  be  necessary.  The  introduction 
of  a  small  quantity  of  paraffin  after  such  dissection  to  keep  the  skin 
trom  readhering  is  irood  practice.  Subsequently  one  may  comji 


i)  eie 


PLASTIC    Sl'UCKUV    OK    T  1 1  K     NOSK    AND    KAK.  l\4~) 


injection  in  one  or  more  sittings.    Xo  anest liclic  is  required  except    in 
young  individuals  \vlio  would  not   remain  qnict  during  the  injection. 

Many  untoward   results  have  been   reported   from  the  use  of  par 
aflin  injection  and  according  to  Council,  who  has  leathered  them   from 
the  literature,  they  may  he  grouped  as  follows: 

1.  To.ric  absorption  or  ii/to.ric«l  ion. — 'Phis  condition  is  most 
probably  due  to  the  impurities  in  the  paraffin  and  not  to  the  chemical 
absorption  and  reaction  of  the  paraffin  itself.  Too  large  a  quantity, 
about  1  10  of  the  body  weight,  would  have  to  be  injected  before  any 
toxic  symptoms  would  be  observed,  according  to  Jukiill. 

'_'.  Inflammatory  reaction  when  the  proper  teclmic  has  not  been 
carried  out,  in  injecting  too  large  a  quantity  of  paraffin  at  one  time, 
or  if  the  material  contains  any  impurities. 

,'!.  Loss  of  fisstK'  due  to  infection  and  secondary  abscess  forma- 
tion has  been  observed  to  follow  these  injections  when  the  usual  asep- 
tic, precautions  which  are  expected  to  be  carried  out  in  any  surgical 
operation  have  not  been  observed.  Instruments,  the  field  of  operation, 
and  the  material  itself  must  all  be  sterile.  The  skin  offers  the  great- 
est  difficulty,  since  there  are  constantly  many  varieties  of  microorgan- 
isms about  the  nose,  ahe  and  vestibule,  which  are  located  in  and  incor- 
porated with  the  sebum  in  the  glands,  and  are  very  hard  to  eradicate. 
However,  since  tincture  of  iodin  lias  been  employed  before  operation 
for  painting  the  area  even  without  previously  using  any  soap  or  water, 
there  is  less  chance  for  infection  after  these  injections. 

4.  Pressure  necrosis  will  invariably  follow  when  the  paraffin  is 
injected  into  the  skin  proper  rather  than  subcutaneously.  It  will  also 
follow  when  too  great  a  quantity  is  injected  at  one  time  by  shutting  off 
the  blood  supply,  with  a  greater  chance  for  secondary  infection.  Again, 
it  is  essential  to  be  most  careful  if  there  exists  some  constitutional  dis- 
turbance or  local  devitalization  of  the  tissues,  such  as  results  from  scar 
tissue.  Firmly  bound  down  skin  must  always  be  first  liberated  before 
the  injection  of  paraffin. 

f).  Slout/lihtf/  has  been  reported,  especially  when  the  paraffin  was 
injected  while  very  hot.  The  author  agrees  with  many  operators  that 
this  is  very  unlikely,  because  by  the  time  the  paraffin  is  injected  into 
the  tissue  it  has  cooled  off  to  a  decree  approximating1  the  body  temper- 
ature. Since  the  hard  paraffins  (Eckstein  140  )  are  now  employed, 
complication  from  this  cause  seldom  occurs.  Slough  ing1,  however,  does 
occur  when  the  injection  is  made  into  the  wrong  place,  as  into  the 
skin  especially  where  it  is  firmly  bound  down  naturally  or  by  scars. 
This  complication  may  be  avoided  by  first  making  a  subcutaneous  in- 
jection of  sterile  or  normal  salt  solution  or  by  the  subcutaneous  dissec- 


1)46  Ol'F.KATIVK    srWJERY    OF    THE    NOSE,    THliOAT,    AND    EAR. 

tion  and  an  injection  of  three-fourths  vaselin  and  one-fourth  paraffin 
so  as  to  prevent  reaclherence  of  tlie  dissected  surface.  An  incision 
should  be  made  and  plates  of  paraffin  or  Cargile  membrane  introduced. 
Then  injections  are  made  small  in  quantity  until  the  deformity  is  cor- 
rected. It  is  well  to  observe  the  general  condition  of  the  patient  and 
in  syphilitic  cases  a  AVassermann  reaction  should  always  precede  the 
injections  to  be  sure  that  the  blood  is  in  good  condition,  even  when  the 
patient  shows  no  active  symptoms. 

(5.  Sitbinjection  or  the  injection  of  an  insufficient  quantity  can 
scarcely  be  classed  as  an  untoward  result;  it  is  only  necessary  to  inject 
again.  If  subinjections  were  common,  less  disagreeable  results  would 
be  reported. 

7.  Hyperinjection  or  the  injection  of  too  great  an    amount    occa- 
sions the  most  disagreeable  results  met  with  in  this  procedure.     This 
is    especially    true    when    this    mass     undergoes     early     organization. 
lender    these    circumstances    its     removal     by     surgical     measures     is 
required,    since    the    various    solvents,  as  ether,  xylol,  benzine,  chloro- 
form and  heat  have  very  little  effect.     Electrolysis,  the  negative  pole 
being  introduced  into  the  mass,  has  been  suggested  as  beneficial,  but 
the  author  has  found  it  of  no  value  in  a  case  of  paraffinoma  so-called, 
in  which  he  employed  this  method.     Instead    of    making    external    in- 
cisions the  vestibule  may  be  opened.     It  is  well  to  remove  the  excess  of 
paraffin  just  as  soon  as  possible  before  organization  has  taken  place. 

8.  Air  embolism  may  occur,  especially  when  cold  paraffin  is  em- 
ployed.    In  rilling  the  syringe,  the  needle  is  as  a  rule  obstructed  and  an 
air  chamber  remains  between  it  and  the  paraffin  taken  from  the  glass 
tube.     This  should  be  avoided  by  completely  emptying  the  syringe  and 
needle  before  refilling  and  then  forcing  out  fresh  paraffin  through  the 
end  of  the  syringe.     If  a  small  air  bubble  gets  in  below  the  skin  it  will 
do  very  little  harm. 

!).  Paraffin  embolism  is  of  a  more  serious  nature.  In  fact,  it  must 
be  named  as  the  most  dangerous  accident  in  connection  with  paraffin 
injections.  Tin-re  are  several  reports  of  death  from  this  cause  and 
many  grave  symptoms,  as  blindness,  pneumonia,  and  cerebral  embol- 
ism, have  been  recorded.  If  the  needle  is  introduced  below  the  skin 
separately  from  the  syringe  and  no  blood  allowed  to  escape  then  the 
immediate  danger  of  embolism  following  the  fragmentation  of  the  par- 
affin is  obviated.  It  is  thought  that  these  small  particles  getting  into 
the  circulation  cause  the  trouble,  but  the  explanation  is  more  theoretic 
than  real.  After  eight  years  of  personal  experience  with  paraffin  in 
various  methods  and  locations  in  ;i  goodly  number  of  cases,  the  author 


PLASTIC    SfHCKUY    OF    T 1 1  K     XOSK    AM)    KAK.  .'147 

cannot  report   a  single  instance  or  even  a   symptom   referable  to   par 
affin  embolism. 

10.  I'i'hinu'1/   ill/fusion    or   c.i'h'usinn   of   paraffin    will    occur   espe- 
cially after  injecting  for  the  correction   of  a   saddle-back    nose,  when 
the  needle  point  is  allowed  to  go  beyond  the  limits  or  after  injecting  a 
larger  amount  than  one  should,  and  especially  when  using  Cnpiid   (hot) 
para  (Hi  n  or  \-aseliii.     The  loose  areolar  tissues  of  the  lower  lid,  cheeks 
and  eyebrows  are  the  principal   location   for  diffusion  of  the   parallin. 
By  having  the  assistant  hold  his  (infers  (irmly  down  on  the  bony  struc- 
ture over  the  root  of  the  nose,  as  well  as  at  its  side,  a  great  deal  of  this 
danger  will   be  avoided.    Semi-solid   or  cold   paraflin   practically   makes 
this  accident  impossible.     The  author  takes  a  piece  of  dental  modeling 
compound  and   while  warm  and  soft,  molds  it   to  (it  the  above  named 
margins  at  which  the  assistant   holds  his  (infers.     This  insures  abso- 
lutely the  retention  of  the  pa  ratlin  within  the  limits  of  this  mold,  which 
when  it  cools  becomes  very  hard. 

11.  Interference  inlli  lln-  <n-fi<nt  <>]  lln>  niuxcle  <>t  tin'  «1«  or  u'ntfi* 
of  flic  HOSI'. — This  is  most  likely  to  happen  when  a  very  low  deformity 
of  the  nose  is  to  be  corrected.     The  author  has  found  that  the  oppos- 
ing muscles  of  the  constrictors  of  the  a  la1  cannot  act   and   the   patient 
then  complains  of  nasal  obstruction  like  that  due   to    paralysis   of   the 
dilating  or  lifting  muscle  of  the  wind's  of  the  nose.     In  order  to  prevent 
the  paraffin  from  coming  down  too  far  a  finder  should  be  inserted  into 
the  nostril  during1  the  injection  and  the  tip  of  the  nose  raised  upward 
and  outward,  if  a  lateral  injection  is  made. 

l'_!.  /','xr(//>c  of  }>(U'(il)ui  after  injection  can  be  avoided  by  thor- 
oughly molding  the  mass  into  the  desired  shape,  although  this  should 
be  done  even  while  the  needle  is  still  within  the  tissues  so  as  not  to 
get  the  mass  into  one  place.  The  needle  should  he  moved  about,  almost 
withdrawn,  and  reintroduced,  since  the  paraffin  often  sticks  to  the 
needle.  The  needle  should  be  withdrawn  only  after  no  more  parallin 
whatever  is  escaping  from  it.  It  escapes  usually  for  a  few  moments 
even  after  the  turning  of  the  piston  ceases  on  account  of  the  pressure 
within  the  syringe.  A  line  blunt  pointed  probe  should  be  passed 
through  the  opening  of  the  skin  so  as  to  be  sure  that  no  parallin  is  left 
in  the  skin  puncture.  A  drop  of  collodion  will  further  close  the  punc- 
ture and  prevent  the  escape  of  any  paraffin.  Xasal  motion  or  manipu- 
lation should  be  prevented.  If  liquid  paraffin  is  employed  under  such 
circumstances  cold  applications  for  a  few  moments  are  advisable. 

1.').  Solidification  of  the  i>nni1fin  in  the  syringe,  or  more  fre- 
quently within  the  needle,  is  a  condition  that  complicates  the  technic 


.'548  OPERATIVE    STRiiERY    OF    THE    XOSE,    THROAT.    AND    EAK. 

very  much,  especially  when  paraffin  of  high  melting  ])oint  is  used.  The 
injection  must  bo  accomplished  quickly,  frequently  necessitating  the 
heating  of  the  needle  over  a  flame  just  before  introduction — a  process 
which  may  be  injurious  to  the  skin.  Again  the  sudden  expulsion  of  the 
liquid  paraffin  into  the  tissues  may  cause  it  to  pass  into  undesirable 
locations  or  too  much  paraffin  may  be  injected  at  one  time,  causing  all 
the  complications  of  hyporinjoctions.  The  fact  that  semi-solid  par- 
affins in  the  cold  state  are  mainly  employed  now,  makes  this  occurrence 
rare.  It  appears  to  the  author  that  when  the  same  syringe  that  is  em- 
ployed for  the  semi-solid  paraffin  is  used,  however,  with  a  very  short 
and  conical  needle,  the  solidification  of  the  paraffin  is  obviated.  By 
rapidly  screwing  the  piston  down,  the  injection  can  be  more  readily 
controlled. 

14.  Alixorption  antl  dix  inter/ rat  ion  of  the  paraffin  injected  are  of 
considerable  interest  and  importance.  Some  authors  believe  that  the 
injected  mass  becomes  encapsulated  by  a  fibrous  capsule  like  a  foreign 
body,  while  many  others  with  histologically  examined  tissue  as  proof, 
believe  that  the  mass  is  first  surrounded  with  a  connective  tissue  wall, 
and  that  fibrous  bands  traverse  the  mass  and  subdivide  it.  The  par- 
affin finally  becomes  absorbed  and  all  that  is  left  is  a  new  connective 
tissue  mass  of  cartilage-like  consistency  to  the  touch.  The  ultimate 
absorption  of  the  paraffin  does  not  seem  to  have  any  effect  on  the  gen- 
eral condition  of  the  individual.  The  time  required  for  the  paraffin  to 
become  absorbed  varies  according  to  the  kind  of  paraffin  injected,  the 
amount  and  location  of  the  injection,  and  differs  even  in  different  indi- 
viduals. Some  authors  have  found  that  after  one  month  a  good-sized 
mass  was  entirely  replaced  by  connective  tissue,  while  others  have  found 
paraffin  as  late  as  four  months  after  injection.  The  harder  the  par- 
affin the  longer  will  it  remain  and  the  less  will  it  be  traversed  by  con- 
ned ive  tissue.  In  loose  connective  tissue  areas  absorption  will  be 
more  rapid  than  in  closely  bound  down  areas.  Small  quantities  in- 
jected at  a  time  will  be  absorbed  more  rapidly  than  larger.  It  is  of  in- 
terest to  note  the  action  of  the  newly-formed  connective  tissue  as  to 
absorption  and  contraction  on  taking  on  nooplastic  manifestations. 

I.").  I)i  Ijlcull  K'S  as  /<>  /l/c  jit'oficr  iiicllu/fi  point  of  I  lie  jxira  /Jin.-- 
In  this  regard  widely  different  opinions  are  expressed.  However  the 
great  number  of  operators  believe  that  paraffins  of  lower  degrees, 
molting  point  from  !>7  to  11.")  K.,  arc  the  best  for  the  purpose.  The 
author  believes  thai  the  formula  recommended  hv  Kolle: 

I'araHin    (plate  sterile) 

Vaselin    (white  sterile).. 


PLASTIC   snicKitv   or   'I'liK    NOSK   AND   KAI:.  .'!4!> 

is  the  best  to  employ,  (ilass  tubes  may  he  prepared  sterile  in  advance 
and  in  these  the  para flin  may  he  resterilized,  tnhe  and  all,  just  het'orc 
the  injection,  hy  washing  with  hichloi'id  and  alcohol.  The  injections 
should  he  made  with  this  semi-solid  paraffin  in  a  cold  state  hecanse  the 
complications  and  unpleasant  results  may  thus  he  avoided. 

1(5.  II  t/ficrxi'itxif  in'Hrxs  of  the  skin  plays  a  very  small  role  in  the 
objections  or  difficulties  met  with  in  the  use  of  paraffin  injections.  I  sn- 
ally  for  a  short  time  only,  twenty-four  to  forty-eight  hours  after  the 
injection  is  made,  is  there  any  complaint  of  pain.  More  often  patients 
complain  of  a  sense  of  distension  or  of  a  drawn  feeling.  Late  symp- 
toms rarely  develop  if  cold  paraffin  is  used  in  small  amounts  at  a  time 
and  if  some  little  time  intervenes  between  the  injections.  Harmon 
Smith  reports  a  sense  of  numbness  following  the  injection  and  other 
authors  have  reported  subsequent  neuralgic  pains  from  the  sensory 
nerve  filaments  caught  in  the  newly-formed  connective  tissue 
mass  after  the  paraffin  has  become  absorbed.  If  infections  of  the  skin 
or  subcutaneous  tissue  should  take  place  following'  the  injection,  there 
may  be  some  tenderness  or  hypersensitive-ness  of  the  area  injected. 

17.  Kcthn'x*  of  the  skin  is  a  pretty  constant  result  of  paraffin  in- 
jections. It  varies  a  great  deal  in  decree,  there  being  in  some  cases 
only  a  flush,  while  in  others  a  very  dee])  red  color  follows.  Again  it 
may  simulate  a  grave  acne  rosacea,  with  distinct  new  blood  vessel 
(capillary)  formation.  It  may  also  appear  at  different  times  follow- 
in  !>•  the  injection.  Sometimes  immediately  after  the  injection  has  been 
made,  especially  if  hot  liquid  paraffin  is  employed,  the  nose  becomes 
very  red  and  it  may  continue  so  for  a  long  time.  Again,  the  redness 
and  capillary  formation  may  not  occur  until  months  later.  This  ap- 
pears to  be  due  to  hyperinjections  especially  of  hot  material. 

Redness  is  unquestionably  due  to  pressure,  on  the  venules  such  as 
one  would  obtain  in  Bier's  hyperemia,  and  possibly  to  an  active 
hyperemia,  nature's  part  to  assist  in  absorbing1  the  foreign  body, 
paraffin.  Again,  late  appearance  of  the  redness  is  very  likely  due  to 
cicatricial  subcutaneous  contractions  from  the  new  substitute  connec- 
tive tissue  mass.  Whether  the  chemical  action  of  the  hydrocarbons  lias 
anything  to  do  with  the  redness  of  the  skin  has  not  yet  been  determined. 
The  early  evidence  of  redness  may  be  relieved  by  ice  cold  applications, 
moist  dressings  of  acetate  of  aluminum,  ichthyol  salve,  ten  per  cent 
extract  of  ergotol,  belladonna,  and  adrenalin  internally.  In  later  stages 
the  same  treatment  plus  the  eventual  severance  of  newly-formed  blood 
vessels,  puncturing  of  the  skin  very  superficially,  and  electrolysis  have 
all  been  suggested.  Karlv  cases  when  verv  stormv  and  red.  mav  call 


OPERATIVE    SUROERY    OF    THE    NOSE,    THROAT,,    AND    EAR. 

for  removal  of  some  of  the  injected  mass  and  older  cases  after  all  has 
been  done,  may  require  the  dissection  of  some  of  the  newly  substituted 
mass  of  connective  tissue.  The  author  has  found  that  a  certain  amount 
of  redness  follows  these  injections,  but  that  it  never  lasts  very  long 
and  eventually  disappears. 

18.  Secondary  diffusion  of  the  injected  paraffin  has  occurred   a 
number  of  times,  especially  into  the  loose  tissues  of  the  eyelids.     The 
difficulty  lies  in  the  fact  that  the  paraffin  is  injected  in  areas  tightly 
bound  down,  as  the  root  of  the  nose,  and  finding  a  lack  of  resistance  at 
this  place  it  migrates  into  the  looser  areas.     Tn  all  such  cases  the  use 
of  cold  paraffin  in  small  quantities  will  avoid  this  difficulty;  when  once 
diffusion  or  migration  has  taken  place,  excision  is  about  all  that  can 
lie  done. 

19.  // ypcr/tlaxia  of  the  connective  tissue  following  the  organiza- 
tion of  the  injected  matter  has  been  observed  a  number  of  times,  and 
the  author  had  a  very  pronounced  case  come  under    his     observation, 
which  is  here  illustrated  (see  Fig.  )>29).   The  specific  cause  of  such  new 
formation  of  connective  tissue  in  this  extensive  form  is  not  known,  and 
most  authors  believe  it  to  be  due  to  a  special  predisposition  on  the  part 
of  the  individual,  such  as  is  found  in  the  tendency  to  develop  keloids. 
When  such  a  disfiguring  condition  develops  there  is  only  one  procedure 
admissible — the  complete  excision  of  the  fibrous  mass.     If  there  should 
})e  a  recurrence,  a  second  operation  must  be  performed. 

'JO.  Ycllou'  appearance  and  thickening  of  the  skin  after  these  in- 
jections are  observed  in  rare  instances,  and  they  are  among  the  most 
difficult  conditions  to  deal  with  satisfactorily.  The  cause  is  supposed 
to  be  the  use  of  hard  paraffin  injected  too  close  to  the  dermal  layer  in 
regions  where  there  is  not  enough  loose  underlying  tissue.  The  elec- 
trolytic treatment,  by  making  a  number  of  punctures  at  repeated  sit- 
tings, is  advised.  This  will  bleach  the  area  by  secondary  scar  forma- 
tion and  contraction.  In  case  the  result  from  such  treatment  is  not 
satisfactory,  it  may  be  necessary  to  excise  the  pigmcnted  portions. 

I'l.  ttreakhlfl  doint  of  tissue  and  resultant  abscesses  due  to  the 
pressure  of  the  injected  mass  upon  the  adjacent  tissue  after  the  injec- 
tion has  become  organized  have  been  observed  generally  in  cases  fol- 
lowing trauma.  Abscess  formation  has  been  observed  without  thi- 
cause,  and  may  be  due  to  the  increased  pressure  on  the  blood  vessels, 
causinir  their  obliteration  and  the  breaking  down  of  the  tissues.  The 
treatment  consists  in  making  a  small  incision  and  draining  the  accumu- 
lated purulent  material.  \Vlicn  all  reaction  symptoms  disappear  the 
parts  are  au'ain  injected. 


Fig.  :•'.:>!'. 
Parattinoma   with   attempted   removal. 


I'LASTIC    SfKOKKY    OF    Tl 


NOSH    AND    KAIJ. 


Technic  of  Paraffin  Injections. — Inslntnn-nts. — About  all  that  is 
required  is  a  syringe  which  is  strong  and  not  too  heavy,  with  a  screw  or 
ratchet  arrangement  for  expressing  the  paraffin  slowly,  but  which  can 
also  be  made  to  expel  its  contents  in  heated  liquid  form  in  a  continuous 
How.  There  are  many  varieties  on  the  market,  and  those  of  Harmon 
Smith,  Broeckaert,  Eckstein,  Kolle,  Onodi,  Walker  Dowman  and  the 
author's  are  all  satisfactory.  The  only  difficulty  with  most  of  them  is 
that  they  are  arranged  only  for  the  use  of  semi-solid  paraffin  ex- 
pressed by  the  screw  method,  or  for  the  liquefied  hot  paraffin  in  a 
continuous  flow.  The  author's  syringe  (Fig.  o.'JO)  is  so  constructed  that 
it  may  be  adapted  for  either  variety  of  paraffin.  For  the  main  ideas  in 
the  construction  of  this  instrument,  the  author  is  indebted  to  V.  Mueller, 
instrument  maker,  Chicago. 

The  i>'reat  advantage  which  the  instrument  of  Broeckaert  has  over 


Fig.  330. 
Beck's  paraffin  syringe. 

others  is  that  it  can  he  managed  by  the  operator  with  one  hand  while 
the  other  can  he  used  to  prevent  the  paraffin  from  escaping  into  the 
loose  tissues.  Moreover,  when  one  is  injecting  intranasally  the  other 
hand  is  free  to  dilate  the  nostril. 

Various  shaped  needles  will  suggest  themselves  for  use  in  differ- 
ent special  localities.  In  injections  about  the  nose  a  needle  with  too 
large  a  caliber  should  be  avoided,  since  the  opening  will  prevent  heal- 
ing; in  fact,  there  is  greater  liability  to  infection.  Again,  the  bleeding- 
is  greater  from  the  skin,  although  it  is  never  of  any  great  consequence. 

Material. — Paraffin  which  has  a  melting  point  of  110  F.,  with  the 
following  formula  :  sterile  plate  paraffin,  1.1,  sterile  white  vaselin,  120, 
is  made  up  and  filled  into  glass  tubes,  open  at  both  ends  and  having  an 
inner  diameter  exactly  equal  to  that  of  the  tube  in  the  syringe  (0.5 
cm.).  The  ends  are  corked,  and  the  cork-stopper  is  coated  with  a  layer 


351'  OPERATIVE    Sl'RCERV    OF    THE    NOSE.    THROAT,    AND    EAR. 

of  paraffin.  These  tubes  are  always  ready  for  refilling1  the  syringe,  and 
all  that  is  necessary  is  to  wash  them  in  biclilorid  and  alcohol  before 
using. 

Fillni<i  tl/<'  Si/rh/f/c  (icli'tle  the  needle  /'*  attached}. — Tni'n  the  ring 
bar  so  that  it  can  be  slipped  down,  thus  releasing  the  piston  screw. 
Pull  out  the  handle  of  the  syringe,  so  that  the  paraffin  chamber  is 
opened.  Then  uncorking  both  ends  of  a  prepared  tube  and  holding  one 
end  right  over  the  paraffin  chamber  of  the  syringe,  the  paraffin  is 
pushed  into  it  by  means  of  the  metal  rod.  It  should  be  noted  that  the 
end  where  the  needle  is  to  be  attached  is  to  lie  free  from  paraffin;  other- 
wise the  air  thus  included  will  prevent  the  paraffin  from  filling  the  en- 
tire chamber  of  the  syringe,  and  on  injecting,  some  air  will  enter  the 
tissues.  This  may  not  do  any  harm,  but  may  elevate  the  tissues  and 
deceive  the  operator  as  to  the  amount  of  paraffin  injected. 

If  hot  liquid  paraffin  is  to  be  employed,  then  the  ring  bar  is  left 
down  and  the  paraffin  is  drawn  up  through  the  needle.  Instead  of  this 
procedure,  the  syringe  may  be  filled  first  and  the  needle  attached  after- 
wards. The  syringe  should  lie  kept  in  very  warm  water  until  ready 
to  be  used.  It  may,  however,  become  too  hot  and  uncomfortable  to  hold, 
and  for  this  reason  the  author  employs  heavy  rubber  gloves  when 
using  this  method. 

Preparation  »f  Field. — Until  two  years  ago,  thorough  scrubbing 
with  soap  and  water,  biclilorid,  ether  and  alcohol,  was  the  usual  routine 
before  injections,  but  since  then  the  author  simply  has  the  Held 
scrubbed  with  alcohol,  following  which  he  applies  the  ten  per  cent  alco- 
holic solution  of  tincture  of  iodin. 

PARAFFIN  INJECTIONS  IN  XASAL  DEFICIENCIES. — The  skin  must  be 
sufficiently  loose  to  enable  one  1o  raise  it.  If  through  contraction  of  scar 
tissue  or  otherwise  Ibis  is  not  possible,  a  small  incision  must  first  be 
made  and  the  skin  dissected  loose.  If  the  resulting  incision  is  too  large 
and  there  is  danger  of  Ilie  paraffin  exuding,  it  is  well  1o  put  in  a  stitch. 

Injeelioii. —  liaise  the  skin  as  in  any  subcutaneous  injection  over 
the  site  to  be  injected,  and  thrust  the  needle,  apart  from  the  syringe, 
through  the  skin.  The  direction  of  the  needle  is  from  the  root  of  the 
nose  downward.  As  a  rule  no  blood  comes  back  through  the  needle, 
but  if  this  should  occur,  draw  the  needle  slightly  outward  and  pass  in 
a  somewhat  different  direction.  In  order  to  prevent  the  cavity  filling 
with  blood  and  forming  a  liematoma,  it  is  best  to  compress  the  parts 
for  a  few  moments,  before  injecting  the  paraffin.  Xow  attach  the 
syringe  by  holding  the  needle  steady,  and  then  turn  the  handle  while 
holding  the  barrel  of  the  syringe  by  the  crossbars.  An  assistant  holds 
his  fingers  firmly  over  the  root  and  side  of  the  nose  so  as  to  prevent 


PLASTIC    SCKiJKKY    OK    T 1 1  K     N'OSK    AND     KAK.  '.}.)',') 

the  paraffin  from  finding  its  way  into  the  loose  tissue  or  other  places 
where  no  paraffin  is  desired.  If  cold  paraffin  is  employed  this  is  not 
very  likely  to  happen.  It  is  well  repeatedly  to  draw  the  needle  out- 
ward almost  to  the  skin  opening  while  injecting,  in  order  to  liberate  it 
from  the  mass,  and  in  that  way  the  paraffin  will  he  more  uniformly 
distributed.  Again,  a  certain  amount  of  molding  is  possible  while  in- 
jecting, and  this  may  be  aided  by  irrigating  the  skin  with  very  warm 
water  or  hot  compresses.  After  having  given  a  proper  shape  to  the 
injected  mass,  ice  applications  will  facilitate  its  solidification  and  the 
retention  of  its  shape.  The  greatest  care  must  be  exercised,  as  alreadv 
pointed  out,  not  to  inject  too  much  at  one  time;  it  is  better  to  repeat 
the  injection  a  number  of  times. 

PAHAFKIX  INJECTIONS  ix  KAK  DEFICIENCIES. — The  most  frequent  in- 
dication is  the  absorption  of  cartilage  by  pressure,  the  result  of  a 
perichondritis  or  a  hematoma,  and  this  affords  the  best  results  although 
the  defect  may  be  very  large.  The  paraffin  mass,  however,  will  never 
hold  up  the  ear  as  cartilage  did.  The  preparations  are  the  same  as  in 
nasal  injections.  The  liquid  hot  paraffin  gives  better  results  than  the 
cold,  since  it  gives  greater  consistency  to  the  ear. 

After  the  two  layers  of  the  skin  of  the  deformed  ear  are  thor- 
oughly separated  by  dissection,  the  paraffin  is  tilled  into  the  cavity  as 
into  a  bag  and  allowed  to  solidify  somewhat.  Supports  or  splints  made 
by  taking  two  impressions  of  the  other  ear  with  dental  compound 
(front  and  back)  are  employed.  Then  the  ear  is  roughly  shaped  and 
the  excess  of  paraffin  is  allowed  to  escape  through  the  small  incision 
that  was  made.  Then  apply  a  thin  layer  of  cotton,  the  dental  com- 
pound splints,  strap  with  adhesive  plaster,  and  bandage  to  the  side  of 
the  head.  This  is  left  undisturbed  for  one  week  unless  there  should  be 
much  pain  or  fever.  Subsequently  a  cotton  support  and  bandage  are 
worn  for  about  three  weeks,  until  organization  lias  taken  place.  In 
the  subsequent  treatment  of  a  newly-made  ear  by  plastic,  an  injection 
of  paraffin  between  the  skin  layers  may  undoubtedly  be  beneficial  to 
tlui  consistency  and  appearance  of  the  ear. 

Paraffin  Injections  in  Collapsed  Alae. 

Mcnz<>l's  Mt'fliod— 

1.  Pack  the  nose  (vestibule)   firmly  with  cotton. 

2.  Pass  the  needle  under  the  skin  overlying  the  cartilage  at  the 
crease  between  the  nose  and  cheek,  forward  and  upward. 

I).  Distribute  the  injected  mass  (equal  parts  of  paraffin  and  vas- 
olin)  over  the  ala  so  as  to  stiffen  it,  but  not  to  any  great  degree,  so  that 
when  the  cotton  is  removed  from  the  nose  the  inner  surface  will  not 


:554 


Ol'KHATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 


approach  the  septum.   Cotton  packing  is  permitted  to  remain  for  twenty- 
four  hours. 

VIII.     Reduction  Method. 

In  order  to  diminish  as  a  whole  or  in  part  the  size  of  a  nose  enlarged 
by  some  pathologic  condition,  traumatism,  or  deformity  of  unknown 
origin,  extranasal,  intranasal  or  combined  methods  may  be  employed. 
Thus  it  is  that  resection  of  a  portion  of  the  nasal  septum  by  the  in- 


Fig.  331. 


Cd  r  t  i    <aj  e 
oj  S«pt  u  YW 


Super/  o  r 
rt  a  x  i  ( I  a. 


Lower    Latero.1 
C  4  rt  1 1  A  Q 


Fi-.   332.  Fig.   333. 

Joseph's  operation   1'or  reducing  hump,   length,   \\iiltli   of  nose  and   largo    nostrils. 


tranasal  method  will  influence  the  shape  of  the  nose,  but  alone  will 
seldom  straighten  it.  By  intranasal  methods,  thai  is  through  incision 
within  the  ahe,  redundances  may  be  removed  or  displaced  so  as  to  fill 
out  deficiencies  in  the  nose.  A  very  largo  nose,  affected  with  chronic 
rosaceous  hypertrophy,  requires  operation  by  external  methods.  Also 
many  very  lar.u'e  hump  and  twisted  noses  are  best  attacked  by  external 
methods.  The  minor  deformities,  as  large  ahe  or  large  nostrils  or  a  verv 


PLASTIC    Sn«;KHY    OK    TIIK     NOSK    AND     KAK. 


ig-   334.  Fig.  ;.35. 

Kolle's  operation  for  hump  nose. 


Fig.  337. 


Beck's  operation  for  hump  nose. 


.'>56  OPERATIVE    Sl'RdEHY    OF    THE    NOSE,    THROAT,    AND    EAR. 

long  hanging  tip  of  the  nose,  arc  as  a  rule  best  corrected  by  external 
methods. 

Joseph's  Operation  for  Reducing  Hump,  Length,  Width  of  Nose  and 
Large  Nostrils. 

1.  An    A-shaped    incision    is    made    over    the    anterolateral    por- 
tion of  the  nose,  just  above  the  tip.     A  corresponding  incision  is  made 
above  this,  the  distance  depending  on  the  amount  of  tissue  that  is  to  be 
removed.     The  ends  of  these  incisions  should  reach  to  the  margins  of 
the  ahr.    (Fig.  .TH.) 

2.  .V  wedge-shaped  portion  of  the  nose  is  now  taken  out,  includ- 
ing the  skin  between  the  two  incisions,  the  underlying  connective  tis- 
sue and  cartilage.     The  hum])  or  crest  of  the    nose,    containing    bones 
and  cartilage,  is  shaved  off  by  means  of  the  chisel  and  the  knife.    (Fig. 
332.) 

.'I.  The  nose  is  shortened  by  excising  a  wedge-shaped  portion  of 
the  cartilaginous  septum,  with  its  base  at  the  dorsmn  of  the  nose  and 
the  apex  running  backward  as  far  as  the  bony  portion  of  the  septum. 
(Fig.  3:53.) 

4.  Suturing  the  parts  together,  one  dee])  suture  should  pass  be- 
tween the  upper  and  lower  margin  of  the  excised  septum  at  the  crest, 
so  as  to  bring  the  point  well  up.  The  other  sutures  are  superficial 
ones. 

.").  The  dressing  should  be  such  as  to  hold  the  tip  of  the  nose  up- 
ward. 

Kolle's  Operation  for  Hump  Nose. 

1.  Make  a  longitudinal  incision  over  the  prominence  of  the  hump 
(Fig.  o.'U)  and  dissect  off  the  skin  and  periosteum  to  cither  side  of  it 
until  it  is  completely  exposed.  (  Fig.  .'>.'>.").) 

'2.  By  the  aid  of  a  chisel  the  hump  is  taken  off,  care  being  taken 
not  to  enter  the  interior  of  the  nose  or  to  tear  away  the  mucous  mem- 
brane. If  there  is  a  tear  it  should  be  sutured  at  once. 

').  If  a  broad  bone  defect  is  obtained  by  the  removal  of  the  hum]), 
then  by  the  aid  of  a  heavy  forceps  the  margins  may  be  pressed  together 
to  obtain  a  sharper  ridge. 

4.     ('lose  defect  by   llalsted's  snbcnt icular  periostea!  suture. 

Beck's  Operation. 

I.  Instead  of  the  longitudinal  incision,  a  transverse  one  curved 
upward,  subsequently  to  be  hidden  by  spectacles,  is  made  across  the 
bridge  of  the  nose.  The  ends  of  this  incision  may  go  to  some  distance 
on  the  side  of  the  nose  and  thus  create  a  Hap  which  will  easily  expose 
t  lie  hump.  (  Fig.  .'!.'!(). ) 


PLASTIC  srucKin    OF  TIN-:   XOSK  AND   KAH. 


'2.     By  means  of  a  chisel  take  off  the  hum] >.    (  Fi.u' 
.'!.     ('lose  in  (lie  same  manner  as  in  the  preceding  operation. 
Ballenger's  Operation  for  Hump  Nose  (Intranasal). 

1.      By  means  of  scalpel   feel  the   lower  bonier  of  the   nasal   bones 
and  pass  through  niueons  membrane  bclwccn  the  skin  and  nasal  bones. 


Fig.  338. 
Ballenger's  operation  for  hump  nose 


FiR.  339. 
Ballenger's   operation    for    Ions    nose. 

•J.      Klevate  the  skin  from  the  underlying  anterior  portion  of  the 
nasal  bones  by  tho  aid  of  a  Freer  ty]»e  elevator. 

.'5.      Introduce^  the   Balleiii>-ei'  reverse  chisel   and  with  a  downward 
and  forward  pull,  parallel  to  the  bridge  of  the  nose,  shave  off  the  hump. 
(Fig.  338.) 
Ballenger's  Operation  for  Long  Nose. 

1.     Make  two  incisions  through  mucous  membrane  and   cartilage 
to  the  opposite  iiiucoperichondriinn  above  the  point  of  the  nose  close 


358  OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT,    AND    EAR. 


Fig.  340. 


Fig.   341. 


Fig.  342. 


Fig.  343. 


Fin.   344. 


line's     operation     for     hump,     twist     and     broad     ala     or     large    nostrils. 
(Illustrated   by    Heck.) 


PLASTIC  sritcKin    OK  TIIK   NOSK  AND   KAI;. 
to  the  dorsiim  and  carry  downward  and  backward  to  meet  at  the  floor 

of  t  lie  nose.    Dissect   the  llllico|  >ericholldri  11  III  free.     (  Kin'.  .'!.'>!(.  ) 

'2.  At  the  dorsnin  of  the  nose  the  Imse  of  this  cartilage  Hap  is  sev- 
ered and  the  wed.u'e  shaped  piece  removed. 

.'!.  'The  nose  is  elevated  by  a  sort  of  sl'm.u'  bandage  of  adhesive 
plaster,  and  held  thus  for  from  four  to  ei.u'bt  days. 

Roe's  Operation  for  Hump,  Twist  and  Broad  Ala  or  Large  Nostrils. 

1.  Make  an  incision  at  the  junction  of  the  inner  alar  skin  surface 
with  the  nasal  mucous  membrane,  and  pass  below  the  skin  over  the 
cartilage  and  nasal  bones.  (  Fi,u-.  .'140.) 

'2.  Flevate  the  skin  and  subcutaneous  connective  tissue  by  means 
of  elevators  (the  author  prefers  Mayo  scissors,  as  by  opening  the 
blades  the  tissues  are  separated  with  the  least  t  raiiinatism  )  until  the 
entire  hump  is  exposed.  (  Fiix.  .'!41. ) 

.'!.  By  means  of  a  small  saw  the  hump  made  up  of  cartilage  and 
bone  is  sawed  off  (  Fi.u1.  l}4'2)  and  removed.  If,  as  is  frequently  tin- 
case,  the  hump  nose  is  at  the  same  time  twisted  and  depressed,  the 
hum})  is  sawed  off  partially,  but  is  left  attached  above  to  the  fibrous 
tissue  as  a  sort  of  a  pedicle  and  slid  over  into  the  depression.  Here  it 
is  subsequently  retained.  (  Ki.u's.  .'!4.'!  and  .'144.)  This  fibrous  pedicle 
is  not  absolutely  necessary,  as  the  bone  and  cartilage  chip  will  live  any 
way.  If  the  depression  be  i>Teater  than  the  bone  cartilage  chip  can 
fill  out.  small  subcutaneous  tissue  Haps  are  turned  back  into  the  de- 
pression. These  are  as  a  rule  taken  from  the  tip  of  lateral  portions  of 
the  a  la1,  which  also  are  lari>v  in  many  cases. 

4.  Kither  a  soft  metal  or  adhesive  retention  dressing  is  applied 
over  the  nose  and  the  incision  within  the  ala  is  sutured. 

Roe's  Operation  for  Broad  Alae  and  Large  Nostrils.    ( Fi,u\  .''>4.V) 

1.  An  incision  is  made  within  the  nostrils  closer  to  the  exterior 
than  in  the  preceding  operation. 

'2.  The  cartilage  is  liberated  and  part  of  it  is  excised  together 
with  some  of  the  subcutaneous  tissue.  (  Fiir.  ->4(). ) 

.'!.  Suture  and  insert  two  small  rubber  tubes.  Kiir.  .".47  -how- 
final  results. 

Beck's  Operation  for  Hump  Nose. 

1.  Lift  up  tip  of  the  nose  and  make  with  a  knife  a  small  semi- 
circular incision  in  the  anterolateral  portion  of  the  vestibule  at  the 
mucocutaneous  junction  of  the  cartilage  and  bone. 


360 


OPKKATIVK    STKtiKHY    ()!••    THK    XOSK,    THROAT,    AND    EAR. 


Fig.   345.  Fig.   846.  Fig.   347. 

Roe's  operation  for  broad  ahv  or  large  nostrils.      (Illustrated  by  Beck.) 

'2.  Dissect  over  the  Immp  with  Mayo 's  scissors  as  in  Fi(u;.  .'US.  With 
the  same  scissors  en,<>;aii;e  and  sever  the  hump  which  is  usually  made  up 
of  eartilau'e. 


Fig.   :', 
Heck's  operation    Tor  hump   nose. 


•'!.  Displace  this  fragment  hy  external  manipulation  and  hy  tin- 
aid  of  line  forceps  or  the  scissors  in  the  eventually  existing  depression 
(it  none  exist  reino\"e  t  he  piece). 


PLASTIC  sri;<;Ki;y   or  TIIK   NOSK  AND   KAI;. 


4.  It'  the  base  from  \vliicli  the  hump  is  removed,  is  very  broad  and 
sharp,  the  ed^es  may  he  filed  off  with  a  straight  rasp  or  shaved  off  with 
a  chisel. 

.").      The  Mood  expressed   from   the  cavity   is  mopped   away  and  an 


CL- 


Fig.  351. 
Kolle's  operation  for  long  tip  nose. 

adhesive  plaster  is  drawn  tightly  over  the  bridge  of  the  nose  with  no 
dressing  between  it  and  the  skin. 

(>.      One  silk  stitch  is  used  to  close  the  wound. 

Kolle's  Operation  for  Long  Tip  Nose. 

1.  Make  an  incision  on  either  side  through  the  entire  thickness  of 
the  nose,  including  the  septum,  as  shown  in  Fiu'.  .''4!),  beirinninu1  at  r, 
downward. 


OPERATIVE    SURtiERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

2.  From  c  to  //,  in  a  natural  curve  line,  all  the  tissues  of  the  ahr 
are  severed. 

3.  A   short  upward  cut  is  made  through  the  entire  thickness  of 
the  columella  at  c,  from  which  point  the  septum  is  cut  as  shown  in  the 
dotted  line  fl ,  towards  c. 

4.  The  tip  b  of  the  part  <t  is  now  cut  off,  leaving  the  nose  as  in 
Fig.  350. 

5.  The  front  part  a  is  now  sutured  to  the  remaining  portions  of 
the  columella  at  b,  and  the  cartilages  of  the  ahr  where  they  are  pro- 
truding are  excised  to  such  an  extent  as  to  permit  union  of  the  skin 
over  them,  as  shown  in  Fig.  351. 

IX.     Prothetic  or  Artificial  Noses. 

There  are  frequently  anatomic,  pathologic  and  social  conditions 
that  require  the  correction  of  the  nasal  deformity  to  be  made  by  the 
aid  of  artificial  devices.  It  can  be  said  without  question  that  so  far  as 
the  appearance  is  concerned,  at  least  if  not  too  closely  scrutinized,  an 
artificial  nose  that  is  correctly  made  looks  much  better  than  one  that 
results  from  the  most  of  the  best  surgical  procedures.  (Figs.  .'552-355. ) 

For  instance,  in  cases  of  carcinoma  which  have  been  operated  up- 
on to  the  extent  of  removing  the  greater  part  of  the  nose,  there 
will  naturally  be  some  hesitation  about  performing  a  plastic  opera- 
tion. In  cases  where  the  face  is  all  scarred  up  it  is  much  better  to  em- 
ploy an  artificial  nose.  There  are  some  people  who  have  not  the  neces- 
sary time  to  have  plastic  work  done  on  their  noses  by  reason  of  the 
necessity  of  making  a  living  and  providing  for  their  families. 

These  artificial  noses  may  be  made  to  fit  any  kind  of  defect  and 
are  usually  held  in  place  by  spectacles  and  adhesive  (actors')  paste. 
The  making  of  these  noses  is  left  to  a  specialist  in  this  line,  but  only 
under  the  direction  of  a  physician,  since  the  condition  of  the  nose  must 
be  thoroughly  examined  before  fitting  an  artificial  nose. 

Artificial  Supports. —  In  noses  in  which  the  bony  framework'  is 
destroyed  or  absent  one  may  introduce  wire  or  rubber  supports,  made 
especially  for  each  individual  case.  In  cases  of  lues,  in  which  t  here  exists 
a  perforation  in  the  hard  palate,  a  sort  of  a  horn  may  be  vnlcani/ed 
upon  a  dental  plate  that  will  push  the  collapsed  nose  forward  and  thus 
support  it. 

X.     Orthopedic  Method. 

By  wearing  certain  forms  of  apparatus  which  usually  must  be 
specially  made  in  each  individual  case,  a  deformity  may  be  changed, 
especially  in  early  life  or  when  it  follows  a  traumatism.  It  is  also  pos- 


CLASTIC    STUCKKY     OK    T  1 1  K     NoSK    AND     KAI! 


Fig.  xr>-2. 


Prothetie  or  artificial  noses. 


3(54 


OPERATIVE    STKliERY    OF    THE    XOSE,    THROAT,    AND    EAH. 


sible  to  correct  collapsed  or  saddle-back  nose  by  special  methods.  (Fig. 
324.) 

XI.     Operations  for  Closing  Perforating  Septum. 

Goldstein's  Operation. 

1.  Freshen  up  the  edges  of  the  perforation  and  elevate  the  muco- 
perichondriuin  from  the  cartilage  for  about  one-half  inch. 

L*.  Remove  a  small  rim  of  the  cartilage  all  along  the  perforation 
by  means  of  Ballenger's  single-fined  swivel  knife.  (Fig.  .'!")().) 

.').     Outline  a  mucoperichondrial  Hap  on  the  most  convenient  por- 


Fig.  356. 


Fig.  357. 


Fig.   358. 
(loldstein's   operation    for   perforation   of  septum. 

lion  of  the  septum,  \vitli  the  hinge  pedicle  at  the  margin  of  the  per- 
foration. The  author  would  suggest  the  use  of  the  cautery  in  order  to 
destroy  the  epithelium  so  that  the  flap  may  heal  more  easily.  (Fig. 

:jf>7.) 

4.  Dissect  this  flap  and  bring  it  between  the  two  layers  of  the 
mucoperiehondrium  about  the  pert  drat  ion. 

.">.  Suture  through  and  through  by  a  quilted  suture  with  the  aid 
of  Yankaiier  needle.  (  Fiir.  .'!.")*. ) 


PLASTIC    Sl'KCKKY     <>!••    T 1 1 K     NOSK    AND     KAK. 

Hazeltine's  Operation  for  Perforation  of  Septum. 

1.  Freshen  ii)»  the  margins  c-c  (  Fi,u'.  .').")!))  and  elevate  the  inuco- 
|M'ricliondriiim  (as  in  the  snbnmcons  resection)  \vliere  the  anterior 
Hap  lies. 

'2.      An    incision    through    the   mnco-perichoiidriniii    about    one  half 


Fig.  35!» 


Fig.  :-!61. 
Hazeltine's  operation   for   perforation   of  septum. 


to  one  inch  anteriorly  to  perforation  (l>-h,  Fiiv.  •'!")!')  is  made,  and  the 
Hap,  with  pedicle  above  and  below,  is  dissected  as  far  as  the  perforation. 
.">.  If  the  anterior  Hap  was  made  on  the  riidit  side,  then  make 
the  posterior  Hap  (r-r.  Fiir.  .">,")!))  on  the  left  side,  by  a  similar  incision 
throuii'li  the  inncoperichondrinm  about  one-half  to  one  inch  back"  of 
perforation. 


366  OPERATIVE    STHllKKV    OF    THE    NOSE,    THROAT,    AND    EAH. 

4.  Approximate  and  suture  anterior  flap  to  posterior  margin 
of  perforation  (/'-/',  Fig.  .'>()())  and  slide  the  posterior  flap  of  the  op- 
posite side  forward  and  suture  to  the  anterior  margins  of  perforation 
(d-d,  Fig.  .'561).  Denuded  areas  (a-u}  from  the  Ha])  heal  by  granulation. 

Goldsmith's  Operation  for  Closure  of  Septal  Perforations. 

1.  Fxcise  margin  of  perforation  by  the  Ballenger's  single-tine 
swivel  knife. 

'2.  Separate  the  mncoperichondrial  flap  on  either  side  all  around 
the  perforation. 

.').  Take  a  piece  of  cartilage  either  from  another  case  just  oper- 
ated upon  for  deviation  by  the  submucous  method,  or  a  piece  of  sheep's 
septal  cartilage,  which  must  be  larger  than  the  perforation. 

4.  Slip  this  cartilage  plate  into  the  dissected  flaps  and  replace 
carefully  all  around  the  perforation. 

.").  Put  in  anterior  nasal  splints  to  retain  the  cartilage  and  niuco- 
perichondrium  in  place  for  forty-eight  hours. 

6.  Subsequent  cauterization  to  assist  in  epitlielialization  and 
application  of  scarlet  red  ointment  constitute  the  after-treatment. 

OTOPLASTY. 

Otoplasty  is  a  subject  that  has  received  very  little  attention  as 
compared  with  rhinoplasty,  and  most  text-books  contain  very  meager 
information  on  the  subject.  However,  much  better  cosmetic  results 
are  obtained  than  in  nasal  plastics,  especially  in  deformities  or  mal- 
positions. In  the  absence  of  the  entire  or  a  greater  portion  of  the 
auricle,  the  results  except  with  prothesis  are  very  unsatisfactory.  There 
is  one  comforting  fact  that  in  women  deformities  of  the  ear  may  be 
hidden  by  lonir  hair.  Far  plastics  are  performed  principally  for  cos- 
m<'1ic  reasons,  since  the  physiologic  function  is  but  slightly  influenced 
unless  it  be  in  eases  of  congenital  atresia,  with  presence  of  a  good 
middle  ear  and  auditory  nerve  apparatus. 

Classifications  According  to  Kolle. 

,       ,,  ,.   .  I   rnilateral. 

I.      Preaiirieular  deficiency   - 

[  Bilateral. 

\  Cnilateral. 
II.      I  ostauriciilar  denciencv 


PLASTIC    SrUCKKY    OK    T 1 1  K     .NOSK    AM)    KAII.  .'J()i 

General  Classification. 

I.  .Macrotia    ( lar.uv  car). 

II.  Asymmetry  of  the  two  ears. 

TIL  Ileterotopy  (false  position  of  the  auricle). 

IV.  Synechia  of  the  posterior  surface  of  the  auricle. 

V.  Projecting,  roll  or  <lo,i>'  ears. 

VI.  Pointed  ear  (Darwinian  tubercle). 

VII.  Macacus  ear. 

VI 1 1.  \Vildermuth  's  ear. 

I  X.  Absence  of  helix. 

X.  Lobule  deformities  and   abnormalities. 

X  I.  Synechia    of   lobule. 

XII.     Shriveled   ear   following;   perichondritis   or   infected    liematonia 

or  abscess. 

XIII.     Traumatic  destruction,  complete  or  partial. 
XIV.     Poliotia. 
XV.      Microtia. 

Usual  Operation  for  Macrotia. 

1.      Ivxcise   a    V-shaped    segment   of   the   auricle,    including   all    the 
structures  at  the  upper  and  larger  part.     The  base  of  the  V  is  at  the 


Fig.  362. 


Fig. 


Fig.   364. 


36S 


OPERATIVE    SURdERY    OF    THE    NOSE,    THROAT,    AND    EAR. 


external  border  of  the  ear.  (Fig.  '•}()-  and  .'>(>.'>.)  The  size  of  the  wedge- 
sha])ed  piece  to  be  removed  will  depend  on  the  size  of  the  deformity 
to  be  corrected. 

'2.  Excise  a  narrow  wedge-shaped  segment  from  the  lower  half 
of  the  auricle,  the  base  of  this  wedge  being  at  the  incision,  the  apex 
directed  towards  the  lobule.  (Fig.  o(>4.)  This  is  necessary  to  make 
the  upper  and  lower  portions  of  the  auricle  fit  for  exact  approximation 
of  the  helix. 

.'}.  Suture  the  lower  wedge  first  and  then  the  large  transverse 
defect  after  exact  approximation. 


Fig.  365.  Fig.  :!66. 

Parkhill's  operation   1'or   inacrotia. 

Parkhill's  Operation  for  Macrotia. 

1.  Make  an  incision  through  all  the  structures  in  line  with  the 
curve  of  the  antihelix. 

'2.  From  each  extremity  of  this  incision  make  a  curvilinear  in- 
cision towards  the  outer  margins. 

.'!.  A  small  tongue-shaped  flap  is  further  excised  from  this  last 
incision  towards  the  external  border,  in  order  to  shorten  the  1 011.11; 
diameter  of  the  ear,  and  the  crescentic  excision  will  make  the  width 
of  the  ear  smaller.  This  will  make  a  crescent-shaped  defect  with  a 
little  longne.  (  Fig.  .'Hi.").)  Suture  defect.  (  Fig.  .'Hi*;.) 

Cheyne  and  Burghard's  Operation  for  Macrotia. 

1.  Excise  a  V-shaped  piece  of  the  auricle  from  the  upper  and 
outer  part,  the  acute  angle  of  the  V  being'  carried  almost  into  the 
concha.  (  Fig.  .'!<>7. ) 


PLASTIC    SUmJKHY    OF    Til  K    NOSH    AND    KAK. 


'2.  Corresponding  to  the  upper  border  of  the  concha  a  semilunar 
incision  is  made  through  all  the  structures. 

3.  From  the  hitter's  extreme  ends  two  short  curved  incisions  arc? 
made   to   meet  the   V-shaped    incision,    removing   the-   two    pieces   thus 
formed.    (  Fig.  307.) 

4.  The  parts  are  brought  together  and  sutured  on  both  sides  of  tin- 
auricle.    (Fig.  36S.) 

Goldstein's  Operation  for  Macrotia. 

1.  Make  a  curvilinear  incision  down  to  the  cartilage,  with  its 
convexity  directed  to  the  outer  margin  of  the  ear,  on  the  posterior 
surface  of  the  auricle.  (Fig.  369.) 


Fig.  367.  Fig. 

Cheyne  and  Burghard's  operation  for  macrotia. 


'2.     Dissect     off    this    flap    and     lay    over    the    mastoid     region. 
(Fig.  370.) 

3.  Cut  through  the  cartilage  in   the  perpendicular   direction   of 
the  ear  and  curve  the  incision  at  each  extremity  for  a  short  distance 
in  order  to  make  a  sort  of  a  cartilage  flap.     Great  care  must    be    exer- 
cised not  to  cut  through  the  skin  on  the  anterior  surface  of  auricle,  in 
other  words,  not  to  buttonhole  it.    (Fig.  370.) 

4.  With  a  dissector,  as  employed  in  a  submucoiis  resection  of  the 
septum,  the  dermopericliondrium  is  dissected  off  from  the  cartilage, 
thus  making  the  cartilage  flap,  and  the  dissection  is  continued  a  little 
beyond  the  necessary  limits  so  as  to  enable  one  to  slide  the  flap  over 
with  greater  ease. 


370  OPERATIVE    SURCiERY    OF    THE    XOSE,    THROAT,    AND    EAR. 


..b 


Fig.   369. 


Pig.  370. 


-f 
..b 


Fig.  371.  Fig.   372. 

Goldstein's  operation    for   marrot  ia. 


PLASTIC    SLTR(!KKY    OF    THE    NOSK    AND    KAH.  371 


.").  Dissect  also  the  dermoperichoiidriinn  anteriorly  from  the 
external  portion  of  tin;  exposed  cartilage  because  the  subsequent  sutur- 
ing will  liave  to  be  done  at  tliat  ]>,oint. 

(>.  Pass  a  small  sharp  curved  needle  armed  with  fine  chromici/cd 
catgut  through  the  ii|>j)er  part  of  the  internal  cartilage  ilap  ( which 
will  become  the  overriding  one).  Then  at  the  same  place  pass  the 
needle  tli rough  the  external  cartilage  Ilap,  which  will  become  the  over- 
ridden one,  and  taking  in  a  small  Itit  of  cartilage  come  out  through 
both  (laps,  completing  one  mattress  suture.  Another  suture  of  the 
same  type  is  made  in  the  lower  portion  of  the  incision,  and  the  parts 
are  ready  for  suture.  (Fig.  .'57 1.) 

7.  While    the    assistant    holds    the    parts    together    so    as    to    get 
an  overriding  of  the  internal  flap,  the  sutures  are  tied. 

8.  The  posterior  dcrmoperichoiidrium  flap  is  brought  back  again 
and  sutured.    (Fig.  372.) 

Goldstein's  Operation  for  Projecting  Ear. 

1.  Make  two  curvilinear  incisions  back  of  the  auricle,  one  having 
its  convex  border  towards  the  outer  border  of  the  ear,  the  other  towards 
the  occiput,  thus  creating  an  elliptical  flap  of  skin.  (Fig.  373.) 

'2.  Dissect  off  this  skin  flap,  exposing  the  perichondrium  of  the 
auricle  and  the  periosteum  of  the  mastoid.  (Fig.  373.) 

3.  Excise  an  elliptical  portion  of  the  cartilage  of  a  size  depend- 
ing upon  the  amount  of  projection  present.    (Fig.  374.) 

4.  Draw  the  cartilage  towards  the  mastoid  region  and  suture  to 
the  periosteum  at  this  point.    (Fig.  375.) 

f).  (Mose  the  skin  defect  by  a  few  interrupted  sutures.  (Fig.  37(5.) 
grafts. 

Beck's  Operation  for  Roll  Ear  or  So-called  Dog-ear.    (Fig.  377.) 

1.     Make  an  incision  through  the  skin  on  the  posterior   part    of 

the  auricle  in  line  with  the  usual  site  of  the  antihelix. 

•_'.      Dissect  the  skin  freely  on  either  side  of  the  incision,  but  not 

the  perichondrium. 

3.  Fxcise  a  very  thin  sliver  of  cartilage   the   whole   length    of   the 
skin  incision  in  a  curvilinear  shape.    (Fig.  378.) 

4.  Bend  back  the  helix  and  form  an  antihelix  by  doubling  the 
cartilage  upon  itself.      Hold  the  parts  together  on  the  anterior  surface 
of  the  ear. 

5.  Pass  two  mattress  sutures  of  silkworm  gut  through  the  skin, 
perichondrium,    cartilage,    two    layers    of    perichondrium,    cartilage. 
perichondrium  and  skin.     These  are  tied  over  pieces  of  rubber  tissue 
in  order  not  to  cut  into  the  skin.    (Fig.  379.) 


372 


OPERATIVE    SURGERY    OF    THE    NOSE.    THROAT,    AND    EAR. 


Fig.  373. 


Fig.   374. 


Fig.   375.  Fig.   376. 

Goldstein's    operation    for    projecting    ear. 


Fig.  377.  Fig.   378. 

Heck's  operation  for  roll  ear  or  so-called  dog  ear. 


PLASTIC  SUR<;KKV  OF  TIIK   XOSK  AND   KAI:.  .;/.> 

(i.  Fxcisc  small  portions  of  excess  skin  on  the  posterior  surface 
and  make  a  subcuticular  suture. 

rriiis  same  operation  can  lie  adopted  for  the  formation  of  an  anti- 
helix  in  an  ear  that  is  not  rolled. 

Szymanowski's  Operation  for  Reconstructing  an  Auricle. 

1.  Make  an  incision  as  outlined  in  Fig.  .'{SO,  hack  of  the  rudi- 
mentary ear  or  external  auditory  meatiis,  about  the  size  of  the  pinna 
on  the  opposite  side,  taking  in  the  skin  and  all  subcutaneous  tissue 
possible1. 

'2.  Dissect  the  above  outlined  flap  and  fold  at  the  constricted 
middle  part  so  as  to  bring  the  ra\v  surfaces  in  apposition. 

.'>.     Suture  along  the  margins  above  and  below. 

4.  Cover  the  denuded  area  of  defect   by  skin   grafts   or  slide  a 
llap  from  the  occipital  region  and  support  posteriorly  by  gauze  pads. 

Subsequent  ( 'nrrcction. 

5.  Incise  above  and   below  as  shown   in  Fig.   .'181,   placing  small 
triangular  (laps  back  of  the  auricle  and  bringing  the  latter  forward 
into   a   more   projecting   shape.     Also   excise   a   small   portion   of   the 
newly-formed  auricle  from  the  lower  margin,  to  shape  a  lobule. 

Beck's  Operation  for  Synechia  of  Auricle  to  the  Mastoid  Squama. 

1.  Sever  the  adherent  ear  from  the  mastoid  surface  and  place 
between  the  surfaces  gauze  or  rubber  tissue  to  prevent  reunion  and 
wait  for  granulation  formation. 

'2.  Make  a  correctly  outlined  flap  to  cover  mastoid  region  as 
well  as  posterior  surface  of  auricle,  on  the  forearm,  ou  the  side 
opposite  to  the  synechia,  since  the  subsequent  immobilization  is  more 
comfortable  in  that  way.  Place  rubber  tissue  below  this  tlap  to 
prevent  its  reuniting  and  allow  it  to  become  thicker. 

Our  Wrrl-  Later. 

.'!.  Freshen  up  the  surfaces  ou  the  mastoid  region,  turn  the  auricle 
forward  and  suture1  into  the  forearm  llap  on  the  greater  portion  of 
the  defect.  (Fig.  .".Sl'.) 

4.  Apply  regular  plaster  retention  cast  as  in  the1   Italian  plastic 
operation  for  the  nose. 

To/  Dai/*  Later. 

5.  Sever  pedicle  from  forearm  and  suture  on  all   sides,   special 
care  being  taken  to  make  a  natural  fold  at  the  insertion  of  the  auricle. 
This  is  best  accomplished  by  a  spring  wire  like  a  spectacle  frame  over 


374  OPERATIVE    SURGERY    OF    THE    NOSE,    THROAT.    AND    EAR. 


Fi£.  380. 


Fitf.  381. 
S/vmano\vski's   operation    for   reconstructing   an   auricle 


PLASTIC    SURGERY    OF    TJIK    NOSK    AM)    HAI!.  J|«J 

some  light  dressing,  to  he  held  hy  the  wearing  of  spectacles  for  the 
time  being. 

(5.     Suture  defect  in   forearm. 

Instead  of  using  the  flap  from  the  forearm  one  or  two  Wolfe 
grafts,  or  Thiersch  grafting,  may  he  employed  1o  cover  Ili<-  defect. 
Again,  the  sliding  ovei1  of  a  flap  from  the  lateral  portion  of  the  occiput, 


Fig.  381'. 
Beck's   operation   for   synechia   of  auricle   to   mastoid. 

even  though  it  contain  hair,  to  cover  the  mastoid  region,  will  aid  a 
great  deal  and  prevent  the  further  formation  of  a  synechia  on  the 
posterior  surface  of  the  auricle.  The  latter  may  he  covered  hy  skin 
grafts. 

Roberts'  Operation  for  Absence  of  Ear. 

This  author's  procedure  is  very  much  like  the  operation  illustrated 
in  Figs.  )>8-')-,')8(),  except  that  he  employs  only  skin  and  subcutaneous 
tissue. 


376 


OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,,    AXD    EAR. 


Simple  Operation  for  Colobomata. 

Excise  the  scar  margins  so  as  to  obtain  fresh  dermal  layers  and 
suture  anteriorly  as  well  as  posteriorly  with  special  care  at  the  tip 
cf  the  lobule,  since  keloid  is  liable  to  form.  (Fig.  387  and  388.) 

Green's  Operation  for  Colobomata. 

1.  Kemove  the  cicatrized  skin  from  the  notch  without  cutting  it 
away  at  the  tip  limits,  but  pull  it  down.  (Fig.  389.) 


Fig.  38:: 


Robert's  operation    for  absence  of  oar. 

'2.  firing  the  denuded  surfaces  together  and  employ  the  little 
ribbon  of  skin  to  make  a  rounded  margin  of  the  tip.  (  Fig.  3!)0.) 

Monk's  Operation  for  Prominent  Ear. 

1.  Fxcise  a  strip  of  skin  and  subcutaneous  tissue  in  the  form 
illustrated  in  Fig.  3!H,  making  1  he  one  incision  all  along  the.  attachment 
of  the  nnricle  ;md  the  other  corresponding  to  the  degree  of  projection. 


PLASTIC    SfKOFKY    OF    T1IK     NOSK    AND    FAIL 


•  X  t 


The  Hap  is  made  cither  broad  on  the  top,  middle  or  bottom,  depending 
on   the   location  of  the   prominence. 

-.     Stitches  are  carefully  applied  so  as  to  pucker  the  defect  thor- 
oughly, and  perfect  approximation  is  imperative. 


Simple1  operation  for  colobomata. 


Green's  operation    for  eoloboniata. 

Kolle's  Operation  for  Projecting  Ear. 

1.  Make  an  incision  on  the  back  of  the  auricle  three-quarters  of 
an  inch  from  its  outer  margin,  be.n'innin.u1  above  at  the  sulcus  and 
curvinu'  u])\vard  and  outward  and  then  uTadually  downward  until 
the  lower  part  of  the  sulcus  is  readied.  The  skin  only  is  incised. 


378 


OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 


12.  Bleeding  at  once  takes  place  and  by  turning  the  auricle  over 
the  mastoid  and  side  of  head,  an  outline  in  blood  is  made  which 
corresponds  to  the  incision  to  be  made. 

3.  This  second  incision  when  completed  will  outline  a  heart-shaped 
flap,  which  is  removed.    (Fig.  392.) 

4.  An  elliptical  piece  of  cartilage  is  removed  in  extremely  pro- 
jecting ears  without  going  through  the  anterior  skin.    (Fig.  393.  ) 

5.  Suture  the  cartilage   with   catgut  separately  and   then   apply 
continuous   sutures   from   above   downward   to   the    skin    margins   to 
close  the  defect  and  to  bring  the  ear  close  to  the  side  of  the  head. 


Fig.  :i!il. 

Monk's  operation    for   prominent 
ear. 


f  \\ 

Fig.  392.  Fig.  393. 

Kolle's  operation    for   projecting   car. 


0.     Place  a  pad  over  ear  and  use  a  bandage  that  is  not  too  firm. 
7.     Allow  stitches  to  remain  for  nine  days  and  do  not  disturb  the 
wound. 

Postauricular  Deficiencies  or  Retroauricular  Fistulae. 

These  are  as  a  rule  the  result  of  mastoid  operations  (radical) 
which  formerly  were  performed  by  leaving  a  large  retroauricular 
drainage  for  a  long  time;  when  healing  took  place,  the  cavity  was 
lined  by  epithelium  continuous  with  the  outside  skin.  Some  of  the 
(rases,  even  when  the  posterior  bony  canal  was  taken  away  and  the 
membranous  canal  was  split  in  the  usual  plastic  manner,  remained 
open  in  the  back  of  the  car  and  then  there  was  a  cavitv  which  was 


I'LASTIC    SUKdKKY    OF    'IMIK    NOSK    AND    HAH.  379 

lined  by  epidermis  continuous  with  the  skin  of  the  external  auditory 
canal  and  the  skin  on  the  posterior  surface  of  the  auricle. 

Trautmann's  Operation  for  Closure  of  the  Posterior  Deficiencies. 

1.  Incise  the  fistula,  making  two  crescentic  flaps   with  their  ep- 
idermal layer  looking  towards  the  auditory  canal.    (Fig.  394.)     (This 
is   done   only    in    those   cases    in    which    the    usual    plastic   of   external 
auditory  ineatus  in  connection  with  the  radical  mastoid  operation  has 
heen   performed.) 

2.  Stitch  these  two  Haps  with  catgut.    (Fig.  39f>.) 

3.  Dissect    freely    the    skin    and    perichondriuin    over    the    pinna 
and  also  the  skin  and  periosteum  over  mastoid  region.    (Fig.  390.) 

4.  Tnite  these  hy  interrupted  sutures  over  the  two  lower  flaps. 
(Fig-.  397.) 

Von  Mosetig-Moorhoff  Operation. 

1.  Make  a  tongue-shaped  flap  below  the  fistulous  opening,  leaving 
the  hinged  pedicle  at  the  lower  margin.  (Fig.  398.) 

'2.  Dissect  loose,  but  not  too  close  to  the  margin  of  the  opening 
or  else  too  little  blood  supply  will  remain  to  nourish  the  flap.  (Fig. 
399.) 

3.  Freshen   up  the  margin  of  the   fistula   and   loosen   the  margin 
thoroughly  for  suture. 

4.  Turn  the  flap  with  its  dermal   layer  towards  the   inside    (to- 
wards  the   auditory  canal)    and    suture   to   margin    of   fistula.      (Fig. 
-100.) 

5.  Close  newly-formed  defect  by  first  loosening  its  margin   (Fig. 
401  ),    subsequently   either   cover   the    turned-in    flap   with    skin    graft 
or  allow  it  to  granulate  and  cicatrize.     It  becomes  necessary  at  times 
to  make  secondary  corrections  at  the  pedicle  portion. 

Goldstein's  Operation. 

1.  Loosen  the  margins  about  the  fistula  freely  on  the  cartilage  as 
well  as  on  the  mastoid  side,  and  freshen  up  the  margins. 

'_'.  Make  lateral  incisions  to  allow  free  coaptation  of  the  margins 
of  the  fistula.  (Fig.  40±) 

3.  Close  by  means  of  ^Michel's  clips.    (Fig.  403.) 

4.  Allow  the  defects  created  by  counter  incisions  for  relaxation 
to  granulate. 

Ear  Prothesis. 

As  in  nasal  deformities,  there  are  times  when  the  local  as  well 
as  the  general  condition  does  not  warrant  an  operation  of  magnitude; 
under  such  circumstances  much  better  results  are  obtained  by  the 
use  of  a  well-fitting  artificial  ear. 


oSO  OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 


Fig.   394. 


Fig.   395. 


Fig.  :::)»;.  Fig.  3<)7. 

'hf    Trautniann     op'^ratifjii     for    closure    of    posterior    deficiencies. 


PLASTIC    SUHCKHV    OF    THE    NOSK    AND    KAK. 


398. 


Fig.  399. 


Fig.   400.  Fig;.   401. 

The  von   Mosetig-Moorhoff  operation   for  postorior   doficieneies. 


382 


OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AXD    EAR. 


It  is  necessary  at  times  to  shape  the  stump  remaining  so  that  the 
artificial  ear  may  fit  and  hold  properly.  Again  there  may  be  no 
external  part  at  all,  and  then  it  may  be  necessary  to  construct  from 


Fig.  4(iL'.  Fig.  403. 

Goldstein's  retro-auricular  plastic-. 


Fig.  404. 
Celluloid    artificial   car 


tlio  tis>ucs  surround! 
tho  attaHiiiionl  of  Un- 
cial oar. 


tlio  aroa   of  tlio  auditory  moatus  a   plaoo   for 
•otliosis.    Kiir.  404  illustrates  a  celluloid  arlifi- 


PLASTIC    SUWiKKV    OF    THK    XOSK    AND    KAK.  383 

Neuroplasty  for  Facial  Paralysis. 

The  various  plastic  operations  on  the  facial  nerve  are  performed 
for  the  purpose  of  reestablishing  the  function  of  the  peripheral 
branches  of  the  facial  nerve  after  it  has  left  the  stylomastoid  for- 
amen, by  transplanting  this  distal  end  into  another  motor  nerve  or 
approximating  it  directly  to  the  central  or  proximal  portion  of  such 
a  nerve.  All  branches  of  the  facial  nerve  given  off  within  the  temporal 
bone  are  not  influenced  by  anastomosing  procedures.  The  direct  repair 
of  the  severed  facial  nerve  is  not  considered  in  this  discussion  of 
neuroplasty.  The  methods  employed  heretofore  are: 

1.      Facial-spinal  accessory  end  to  end  anastomosis. 

'2.  Facial-hypoglossaJ,  end  (facial  nerve)  to  side  (of  hyperglos- 
sal). 

3.  Facial-hypoglossal,  end  to  end. 

4.  Facial-spinal  accessory  and  descendens  hypoglossi-spinal  acces- 
sory anastomosis. 

f).     Facial-glossopharyngeal  anastomosis. 

The  principles  underlying  neuroplastic  surgery  are: 
1.     The  approximating  nerves  must  be  under  absolutely  no  ten- 
sion. 

'2.  The  neural  structures  of  one  nerve  should  be  in  contact  with 
the  neural  structures  of  the  opposite  nerve.  (This  is  particularly 
necessary  in  the  end  to  side  methods.) 

3.  Suturing  must  be  done  with  the  finest  of  material  and  under 
great  care  (not  so  many  sutures  being  used  as  to  endanger  strangula- 
tion). 

4.  The   anastomosed   nerves   should   be   surrounded   with  muscle 
tissue  or  Cargile  membrane,  to  prevent  too  great  a  cicatricial  forma- 
tion about  them. 

5.  Absolute  asepsis  is  necessary  to  obtain  a  good  result. 

(!.  Adjunct  treatment  such  as  electricity,  massage,  tonics,  etc., 
following  the  operation  hastens  recovery,  the  time  depending  on  the 
degree  of  muscular  atrophy  which  preceded  the  operation. 

7.  Correct  diagnosis  before  the  operation  as  to  the  reaction  to 
degeneration  is  very  important,  so  as  to  be  sure  that  if  a  perfect 
anastomosis  operation  is  performed  and  union  is  absolutely  perfect, 
a  good  result  is  possible;  otherwise  this  excellent  therapeutic  pro- 
cedure would  be  discredited,  as  the  muscle  would  not  be  susceptible 
of  motion  in  spite  of  the  unimpeded  nerve  stimulus. 


384 


OPERATIVE    SURGERY    OF    THE    XOSE,    THROAT,    AND    EAR. 


Spino-Facial  and  Periphero-Spinal  to  Descendens  Hypoglossi 

Anastomosis.  * 

1.  Make  a  Y-shaped  incision,  one  branch  of  the  Y  ending  in  front 
of  the  trains,  the  other  back  of  the  ear  on  the  line  with  the  tragus. 
The  stalk  of  the  Y  is  directed  forward  and  downward,  in  front  of  the 
sternomastoid,  for  about  three  inches  in  length.    This  incision   goes 
through  skin  and  superficial  fascia.    (Fig.  405.) 

2.  Dissect  bluntly  down  to  the  muscles  and  expose  the  posterior 
border  of  the  parotid  gland. 

3.  Ellevate  the  lobule  of  the  ear,  draw  forward  the  parotid  gland 
and  dissect  down  into  the  narrow  space  between  the  anterior  border 


Fig.  405. 
Incision  for  spino-facial  anastomosis. 


of  the  mastoid  and  the  posterior  border  of  the  rannis  of  the  lower 
jaw.  Here  locate  the  facial  nerve  in  its  course  from  the  stylomastoid 
foramen  towards  the  posterior  border  and  the  under  surface  of  the 
parotid  gland. 

4.  Place  a  ligature  (but  not  tied)  around  it  for  subsequent  identi- 
fication and  leave  this  Held  of  operation  for  the  time  being  for  the 
location  of  the  other  nerves.  (Fig.  406.) 

.").  Find  the  spinal  accessory  nerve,  which  is  on  the  line  from  the 
angle  of  the  lower  jaw  backward,  where  it  pierces  the  fascia  of  the 
sternomastoid  muscles. 

o'.  Place  a  suture  about  it  for  the  same  purpose  as  in  the  facial. 
(Fig.  40(J.) 

*C-.ntril.ut<Ml    l,y    W.  W.  (Irani,  M.  I)..     Dt-nver. 


PLASTIC    SUHOKHY    OF    TIIK    XOSK    AND    KAH.  ,jcS:j 

7.  Expose  the  hypoglossal  which   lies  in  this   region,  just    where 
the  occipital  artery  is  given  off  from  the  external  carotid,  about   the 
central  tendon  of  the  digastric  muscle. 

8.  Out  the  digastric  muscle  posterior  to  its  central    tendon    and 
reflect  this  posterior  belly  backward. 


•--Descenden 
bypo^lossi 


Fig.  406. 
Spino-t'acial  and  periphero-spinal  to  descendens  hypoglossi  anastomosis. 

9.  Locate  the  descendens  hypoglossi  at  this  point  as  it  leaves 
the  hypoglossal  and  passes  downward  on  the  sheath  of  the  common 
carotid  artery.  Place  a  thread  about  this  nerve  also.  (Fig.  406.) 


386  OPERATIVE    SUKtiKHY    OF    THE    NOSE,    THROAT,    AND    EAR. 

10.  Go  back  to  the  facial  nerve,  draw  it  out  so  as    to    be    able 
to  reach  the  end  that  comes  from  the  stylomastoid  foramen  and  with 
a  pair  of  slender  scissors  sever  it  close  to  this  foramen  and  pull  out 
this  end  of  the  nerve. 

11.  Pull  on  the  spinal  accessory  and  sever  it  .just  before  it  enters 
the   sternomastoid   muscle,   making   sure   before4   it   is   severed   that   a 
long  enough   segment  may  lie  drawn  to  unite  with   the    facial   stump 
without  occasioning  any  tension  when  their  ends  are  united. 

ll'.  Have  an  assistant  hold  both  ends.  Then  cut  off  the  spinal 
accessory  and  the  peripheral  end  of  the  facial  in  close  and  exact 
approximation,  the  operator  suturing  them  with  tine  linen  thread,  and 
using  a  small  round  needle.  One  suture  is  to  be  made  at  each  side, 


Fig.  407. 
Beck's  nerve  tracing  forceps. 

possibly  including  some  nerve  fibres,  and  another  supporting  suture 
through  the  neurilemna  only  on  the  under  surface.  The  sutures  are  tied 
only  moderately  tight. 

1..'!.  To  prevent  cicatricial  constriction,  place  some  Targile  mem- 
brane at  the  point  of  nerve  union  about  this  anastomosis. 

14.  Now  sever  the  descendens  hypoglossi  by  drawing  on  the 
thread  fully  three-fourths  of  an  inch  below  where  it  leaves  the  hypo- 
glossal,  and  turn  this  cut  end  upward. 

].).  Approximate  this  end  of  the  descendens  hypoglossi  and  the 
peripheral  end  of  the  spinal  accessory  with  the  same  teclmic  as  was 
used  on  t  he  facial  nerve. 

Hi.  Reunite  the  digastric  muscle  and  close  the  wound  without 
drainage. 

Facial-Spinal  Accessory  Anastomosis. 

1.      Make  an  incision  through  the  skin   facia  from  behind  the  ear 
forward    and    downward    along  the   anterior   border   of   sternomastoid 
•He,  to  about   the  level   of  the  thvroid  cartilage. 


PLASTIC    SUKGEHY    OF    THE    NOSE    AND    EAH.  387 

I1,  Ketract  and  find  the  spinal  accessory  nerve  as  it  pierces  the 
sternomastoid  muscle. 

-'!.  Dissect  and  retract  forward  over  the  lower  jaw,  exposing  the 
parotid  gland  (posterior  l)order). 

4.     Locate  the  facial  nerve  as  it  enters  this  gland. 

f).  Follow  it  below  the  cartilaginous  portion  of  the  external 
auditory  canal  down  between  the  posterior  border  of  the  ramus  of 
the  lower  jaw  and  the  anterior  border  of  the  mastoid  process. 

(i.  It  may  be  necessary  to  divide  the  posterior  belly  of  the 
digastric  muscle.  Ketract  the  stylohyoid  muscle  and  pass  about  the 
nerve  the  author's  nerve  tracing  forceps.  (Fig.  407.)  Follow  the  nerve 
to  the  stylo-mastoid  foramen,  which  is  behind  the  styloid  process, 
and  close  on  the  nerve. 

7.  Steadily  pull  the  nerve  out  of  the  mastoid  canal  (stylomastoid 
foramen)   and  keep  the  forceps  attached  to  the  nerve. 

8.  Withdraw  as  much  of  the  spinal  accessory  nerve  as  is  neces- 
sary to  make  an  easy  approximation  with  the  dissected   facial  nerve. 

!).  Trim  the  facial  nerve  end  squarely  to  fit  the  spinal  accessory 
and  suture  the  two  end  to  end. 

10.  Three  sutures  are  placed,  going  through  the  neurilemma  and 
taking  in  a  few  of  the  axis  cylinders.   An  additional  supporting  suture 
(continuous)  takes  in  only  the  sheath  of  both  the  nerves. 

11.  Make  a  slit  or  pocket  into  the  posterior  belly  of  the  digastric 
muscle  (if  it  is  divided  it  should  first  be  united),  or  place  a  layer  of 
Cargile  membrane  about  the  anastomosis. 

ll?.     Close  wound. 

Facial-Hypoglossal  End  to  Side  Anastomosis. 

1.  Incise  the  skin,  fascia  and  platysma,  beginning  behind  the  ear 
and  carrying  the  cut  downward  and  then  forward  towards  the  thyroid 
cartilage. 

'2.  Retracing  the  tissues,  the  hypogiossal  nerve  is  located  by 
drawing  up  the  digastric  muscles  posterior  to  the  sternoniastoid 
where  the  sheaths  of  the  great  vessels  lie.  On  the  level  of  the  thyroid 
cartilage,  where  the  carotid  artery  divides  into  the  external  and 
internal  branches,  the  hypogiossal  nerve  will  be  seen  at  the  point  of 
crossing  of  the  occipital  and  the  internal  carotid  arteries.  Here  it 
turns  forward  and  lies  on  the  mylohyoid  muscle. 

3.  Expose  the  hypogiossal  nerve  at  the  point  closest  to  the  facial 
nerve. 

4.  Locate  the  facial  nerve  as  in  the  facial-spinal  accessory  anas- 
tomosis, and  draw  it  out  in  the  manner  described  above  from  the  stylo- 
mastoid foramen. 


388 


OPERATIVE    STRUEKY    OF    THE    NOSE.    THKOAT,    AND    EAR. 


f).  Trim  the  facial  stump  in  such  a  manner  as  to  strip  the  major- 
ity of  the  axis  cylinders  of  their  sheaths  for  about  three  lines. 

(>.  Place  three  sutures  through  this  stump,  thus  getting  it  ready 
to  join  with  the  hypoglossal  nerve. 

7.  Make  a  small  buttonhole  in  the  exposed  hypoglossal  nerve  at 
the  point  mentioned  in  division  3,  parallel  to  the  course  of  the  nerve 
and  on  its  upper  border,  to  admit  the  prepared  facial  stump.  It  is 


nerve  im 
planted  end  to 
Side  in  hypo- 


Kacial-li vno.ulossal  end   to  side  anastomosis 


Posterior  belly 
cut 
reflected 


well  to  enter  this  buttonhole  slit  with  a  fine  pair  of  scissors  and  cut 
a  few  axis  cylinders  transversely  within  the  sheath  in  order  to  get 
direct  contact  with  the  facial  axis  cylinders  and  thus  obtain  a  more 
ra pid  re^-em-rat  ion. 

s.  I'a>>  the  already  prepares!  sutures  of  the  facial  stump  through 
the  slit  in  the  hypoglossal  nerve  Irom  within,  outward,  one  on  each 
>ide  and  the  third  at  one  end.  The  tying  should  be  done  by  the  oper 


PLASTIC    SCIUiKRY    OF    THE    NOSK    AND    KAU. 


ator  while  the  assistant  keeps  the  slit  open  with  a  fine  pair  of  forceps 
(spring)  and  holds  the  facial  stump  steady  in  the  slit.  Another  sup- 
porting suture  surrounds  this  anastomosis  in  the  same  manner  as  in 
the  spinal  accessory  procedure.  (Fig.  40H. ) 

1).  The  same  procedure  as  in  the,  facial  spinal  accessory  is  fol- 
lowed in  the  prevention  of  cicatricial  formation  about  the  union,  as 
is  also  in  the  closure  of  the  external  wound. 

Facial-Hypoglossal  End  to  End  Anastomosis. 

1.     The  same  procedure  as  in  the  end  to  side  operation  up  to  the 


nerve  ^n 

\\W65torao5ed   end 
to  end  with    hypo- 


Descendens    - 
hypqcflossi 


Facial-hypoglossal  end  to  end  anastomosis, 


point  of  union,  except  that  the  hypoglossal  is  not  prepared  so  close 
to  the  facial  nerve.  (Fig-.  409.) 

'1.  Follow  the  hypoglossal  nerve  nearer  to  the  front  as  it  enters 
the  floor  of  the  mouth. 

3.  Sever  the  hypoglossal  and  turn  it  back  to  join  it  with  the 
facial  nerve  which  has  also  been  prepared  as  in  the  other  two  previous 
procedures. 


OPERATIVE    SURfiERY    OF    THE    NOSE,    THROAT,    AND    EAR. 

4.  The  union  and  management  of  the  anastomosis  and  the  wound 
are  subject  to  the  same  procedure  as  in  the  facial-spinal  accessory 
operation. 

Myeloplasty  for  Facial  Paralysis. 

In  cases  of  congenital  facial  paralysis,  or  in  permanent  paralysis 
in  which  the  peripheral  branches  of  the  facial  nerve  are  imbedded  in 
cicatricial  connective  tissue,  or  when  the  paralyzed  muscles  of  the  face 
supplied  by  the  seventh  cranial  nerve  are  completely  atrophied  and  do 
not  react  to  the  electric  currents,  or  finally  if  for  any  reason  the  hypo- 
glossal  or  accessory  nerves  are  not  accessible  and  the  neuroplastic  opera- 
ation  cannot  be  performed  for  any  other  reason,  the  masseter  muscles 
may  be  used  to  obtain  a  straighter  face.  The  associated  movements  fol- 
lowing this  operation  are  objectional.  These,  however,  do  not  persist, 
for  the  patients  re-educate  that  particular  part  of  the  masseter  muscle 
\vhich  causes  facial  expressions. 

Tcclniir. — Under  local  or  general  anesthesia  make  an  incision 
along  the  posterior  border  of  the  ramus  of  the  lower  jaw.  The  tissues 
are  dissected  forward  until  part  of  the  masseter  muscles  is  reached. 
These  are  now  separated  from  their  attachment  to  the  ramus  of  the 
jaw  and  the  lower  border.  A  sort  of  a  tunnel  is  now  made  with  a 
pair  of  Alayo's  scissors,  spreading  the  tissues  rather  than  cutting 
them,  until  one  reaches  the  external  angle  of  the  mouth.  It  is  impor- 
tant not  to  go  too  high  in  order  not  to  wound  the  duct  of  the  parotid 
gland.  As  the  angle  of  the  mouth  is  approached,  care  must  be  taken 
not  to  wound  the  facial  artery.  The  facial  vein  must  sometimes  be 
ligated.  (treat  care  is  to  be  exercised  not  to  penetrate  through  the 
mucous  membrane  of  the  mouth  or  the  skin  externally.  The  masseter 
muscles  already  severed  are  now  armed  on  two  silkworm  gut  sutures, 
with  very  short  curved  needles,  one  on  each  end  of  the  thread  so  as  to 
have  four  needles  in  all.  One  thread  is  now  passed  close  to  the  upper 
lip,  through  the  subcutaneous  tissue  and  skin,  while  the  second  thread 
is  placed  close  to  the  lower  lip.  These  sutures  are  tied  over  a  piece 
of  gauxe  to  prevent  their  cutting  in.  The  wound  is  closed  completely 
without  drainage. 

During  the  next  three  weeks  the  patient  takes  only  liquid  diet  in 
order  not  to  use  the  masseter  muscles.  The  stitches  holding  them  are 
removed  at  the  end  of  ten  davs,  as  are  also  those  of  the  incision. 


-H 
~ 

-D 


£55 


m 


Date  Due 


PRINTED   IN    U.S.*.  CAT       NO.     24      161 


UC  SOUTHERN  REGIONAL  LIBRARY  FACILITY 


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LP25   o 
101U 

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Loeb,   Hanau  W 

Or>erative   surpery  of  the  nose, 
throat ,    and    ear... 


WV168 
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v.l 
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Operative  surgery  of  the  nose,  throat, 
and  ear. . . 


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